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A  MANUAL  OF 
MODERN   GASTRIC    METHODS 


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[Photo  by  J.  Hume  Paterson. 
Fig.  1.— Auto-lavage.    (See  page  119.) 


A    MANUAL 

OF 

MODERN  GASTRIC  METHODS 

CHEMICAL,  PHYSICAL,  AND  THERAPEUTICAL 

BV 

A.   LOCKHART    GILLESPIE 

M.D.,  F.R.C.P.E.,  F.R.S.E. 

Lecturer  on  Materia  Medica  and  Therapeutics  in  the  School  of  Medicine  of  the  Royal 

Colleges,  Edinburgh  ;  Post-Graduate  Lecturer  on  Modern  Gastric  Methods, 

Edinburgh  ;   Medical  Registrar,  Royal  Infirmary,  Edinburgh 

Author  of 
"The  Natural  History  of  Digestion"  (Contemporary  Science  Series) 

WITH   A   CHAPTER   UPON' 

THE    MECHANICAL    METHODS    USED    IN 
YOUNG   CHILDREN 


JOHN   THOMSON,    M.D.,    F.R.C.P.  Ed. 

Assistant  Physicia7z,  Royal  Hospital  for  Sick  Children,  Edinburgh 


NEW   YORK 
WILLIAM   WOOD    &   COMPANY 

1901 


Wt)<?\'<^     X^vjLcA\.a-*t«?^  ' 


TO 

CLAUD    MUIRHEAD,    M.D.,  F.R.C.P.  Ed. 

TO   WHOSE 

PRECEPTS   AND   PRACTICE 

THE 

AUTHOR     IS     DEEPLY     INDEBTED. 


PREFACE 

In  response  to  many  requests  the  following  notes 
have  been  put  together  in  the  hope  that  descriptions 
of  the  different  modern  schemes,  which  have  been 
adumbrated  for  the  purpose  of  helping  a  physician's 
diagnostic  powers,  and  therapeutic  facilities,  in  con- 
nection with  gastric  complaints,  might  serve  a  useful 
purpose  when  expressed  succinctly,  and  based  upon 
a  personal  acquaintance  with  the  actual  details  of 
the  processes.  Practical  performance  of  methods, 
carried  out  entirely  at  second  hand  from  text-book 
directions  (often  transcribed  by  the  authors  without 
a  personal  trial),  giving  but  bare  details  of  the  modus 
operandi,  is  apt  to  result  in  failure,  or  error,  until  the 
physician  has  found  out  by  his  own  experience  what 
precautions  and  additions  are  advisable.  As  many 
of  the  chemical  methods  of  analysis  are  too  compli- 
cated and  lengthy  for  ordinary  clinical  work,  the 
details  of  the  more  simple  procedures  have  been 
emphasised,  although  at  the  same  time  the  others 
are  fully  dealt  with. 

Scientific  medicine  progresses  apace ;  in  the  diag- 
nosis and  treatment  of  gastric  diseases  quite  as  rapidly 
as   in   other  departments  ;   the  aid   she   affords   is  of 


X  PREFACE 

great  value,  but  liable  to  misuse.  Science  can  aid 
clinical  knowledge,  but  cannot  take  its  place.  Gastric 
modern  methods  often  afford  us  invaluable  evidence 
as  to  the  true  nature  of  the  disease  and  its  probable 
cause,  but  treatment  founded  upon  them  alone  is  apt 
to  enter  into  conflict  with  the  living  personality  of 
the  victim. 

Dr  John  Thomson  has  been  good  enough  to  supply 
a  chapter  upon  the  mechanical  measures. advisable  for 
use  on  children,  a  subject  on  which,  as  is  well  known, 
he  is  an  expert. 

I  have  to  express  my  thanks  to  my  friends,  Dr 
Max  Einhorn  of  New  York,  and  to  Dr  Fenton  B. 
Turck  of  Chicago,  for  their  kind  permission  to  re- 
produce several  figures ;  to  record  my  deep  sense  of 
gratitude  to  the  Royal  College  of  Physicians  of  Edin- 
burgh for  the  opportunities  so  freely  given  me  of 
working  in  their  Research  Laboratory ;  and  to  thank 
Mr  J.  Hume  Paterson  of  that  Laboratory  for  his  aid 
in  the  preparation  of  the  figures. 

A.  L.  G. 


23  Walker  Street, 
June  l?99. 


TABLE    OF   CONTENTS 

SUBJECT 

CHAPTER  PAGE 

I.  The  Conditions  Present  in  Healthy  Digestion       .  .  i 

II.  The  Methods  for  Obtaining  the  Contents  of  the  Stomach         ii 

III.  The  Examination  of  the  Fluid  removed  from  the  Stomach, 

or  of  the  Vomit  .  .  .  .  .22 

IV.  The  Examination  of  the  Fluid  removed — {Cont.)     The 

Chemical  Examination  .  .  .  .32 

V.  The  Examination  of  the  Fluid  removed — [Cont.)  The 
Quantitative  Estimation  of  the  Difterent  Factors 
which  go  to  make  up  the  Total  Acidity  .  .         47 

VI.   General  Consideration  of  the  Different  Chemical  Methods 

Described        ......         90 

VII.   The  Activity  of  the  Gastric  Juice  .  .  .  .96 

VIII.  The  Determination  of  the  Motility,  Size,  and  Position  of 

the  Stomach  .  .  .  .  .  .108 

IX.  The  ^Mechanical  Methods  used  in  the  Treatment  of  the 

Diseases  of  the  Stomach         .  .  .  .118 

X.  The  Mechanical  Methods  used  in  Young  Children,   by 

John  Thomson,  M.D.,  F.R.C. P.  Ed.  .  .        135 

XI.   Classification  of  Gastric  Conditions  .  .  .        143 

XII.   The  Apparatus  and  Reagents  required  in  the  Examination 

of  the  Stomach  Contents         ....       149 
Appendix.   Recent  Instruments  and  Methods     .  .  .161 


TABLE    OF    FIGURES 


FIG. 
I. 

II. 

III. 

IV. 

V. 

VI. 

VII. 

VIII. 

IX. 

X. 

XL 

XII. 

XIII. 

XIV. 

XV. 


SUBJECT 

PAGE 

Auto-lavage  (&.  p.  119)  .  .  .  .     Frontispiece. 

Stomach  Tubes  {v.  p.  16)             .  .  .  .16 

Boas's  Ball-pump  {v.  p.  20)         .  .  .  .20 

Einhorn's  Stomach  Bucket  {v.  p.  20)  .  .  .20 

Einhorn's  Gastrograph  (z/.  p.  iii)  .  .  .        112 

Einhorn's  Gastric  Spray  {y.  p.  121)  .  .  .112 

Einhorn's  Deglutable  Electrode  (z'.  p.  127)  .  .       112 

Einhorn's  Gastro-diaphanoscope  (».  p.  131)  .  .        132 

Areas  transillumined  in  Normal  and  Dilated  Stomach, 

and  in  Gastroptosis  (z'.  p.  132)         .  .  .        132 

Turck's  Gyromele  {v.  p.  133)      ....       134 

Turck's  Gastric  Resuscitator  {v.  p.  163)  .  .164 

Turck's  Needle  Douche  {v.  p.  164)         .  .  .164 

Turck's  Double  Force  Gastric  Irrigator  and  Aspirator 

{v.  p.  165)    ......       166 


A  MANUAL  OF 
MODERN   GASTRIC    METHODS 


CHAPTER   I. 

THE   CONDITIONS   PRESENT   IN    HEALTHY 
DIGESTION. 

Normal  Gastric  Juice — Capacity  of  the  Stomach — Measurements — 
The  Gastric  Contents — Three  Stages  of  Gastric  Digestion — Dura- 
tion of  the  Stay  of  Food  in  the  Stomach — The  Fasting  Stomach. 

The  normal  gastric  juice  of  man  has  hardly  ever 
been  procured  in  a  pure  state.  The  one  or  two 
instances  in  which  it  has  been  examined  have  been 
cases  of  gastric  fistula,  such  as  the  historic  case 
of  Alexis  St  Martin,  and  the  case  of  a  peasant 
woman,  the  subject  of  a  gastric  fistula,  investigated 
by  Schmidt.  The  composition  of  gastric  juice  as 
obtained  from  these  patients  has  really  little  con- 
nection with  that  of  the  contents  of  the  stomach 
after  a  meal,  either  in  health  or  in  disease.  The 
contents  in  such  cases  have  always  been  obtained 
by  mechanical  stimulation  of  the  mucous  membrane. 
The  proper  stimulation  for  the  gastric  glands  is 
food  of  various  kinds.  The  analyses  of  the  gastric 
juice  obtained  from  cases  of  fistula  by  mechanical 
stimulation  bear  very  little  relation  to  the  char- 
acters of  the  secretion  poured  out  by  the  cells 
of  the  gastric  glands  during  digestion.     Pure  gastric 

A 


2  GASTRIC    JUICE    IN    HEALTH 

juice  is  a  thin,  colourless,  or  slightly  yellow  liquid, 
with  a  faintly  acid,  mawkish  taste,  and  a  peculiar, 
specific  odour.  When  boiled  it  does  not  coagulate, 
but  loses  its  activity.  If  it  contains  a  normal  amount 
of  hydrochloric  acid,  it  may  be  kept  for  a  long  time 
without  decomposition  occurring.  The  analysis  of 
the  secretion  of  the  stomach  during  fasting  may  here 
be  given. 

Analysis  of  the  Gastric  Juice  in  Man,  per  mille 
(containing  saliva). 

Specific  gravity,     .         .         .  I002'00 
Water,  .....  994"40 
Organic  material,  .         .         .  3  19  (Pepsin  3) 
Free  hydrochloric  acid,           .  0"20 
Chloride  of  sodium,        .         .  i'46 
„            potassium,  .         .  0"55 
„             calcium,       .         .  006 
Phosphate  of  calcium   mag- 
nesium, and  iron,    .         .  0"i25 

The  analysis  was  made  by  Schmidt  in  a  case  of 
gastric  fistula.  It  will  be  seen  from  the  table  that 
the  solids  of  the  gastric  juice  are  below  i  per  cent. 
Gamgee*  says  that  the  juice  contains,  as  a  rule,  less 
than  I  per  cent,  of  solids,  f  rds  of  which  are  organic,  and 
about  -3-rd  inorganic.  The  amount  of  hydrochloric 
acid  given  in  the  table  is  only  '02  per  cent.,  but  it 
is  not  stated  whether  the  hydrochloric  acid  present 
was  in  an  absolutely  free  form  or  combined  with 
the  proteid  material  in  the  juice.  The  organic 
solids,  which   are   chiefly  composed   of  the  ferment 

*   Text-Book  of  Physiological  Chemistry,  vol.  ii.  p.  79. 


CAPACITY    OF    THE    STOMACH  3 

pepsin,  amount  to  319  grm.  per  cent,  and  the 
quantity  of  hydrochloric  acid  present  is  not  suffi- 
cient to  satisfy  all  the  affinities  of  this  organic 
matter,  even  if  only  part  of  it  be  proteid  in  nature. 

Pure  gastric  juice  reacts  to  litmus  and  to 
phenol-phthalein  as  an  acid.  We  have,  as  yet, 
no  accurate  knowledge  of  the  amount  of  juice 
secreted.  The  quantity  secreted  each  hour,  accord- 
ing to  Schmidt,  is  500  grm.  in  the  dog,  and  if  we 
reckon  this  as  yV^h  of  the  dog's  weight,  in  man 
6  litres  each  clay  should  be  formed.  But  Fremont 
found  that  the  amount  of  pure  gastric  juice  secreted 
by  an  isolated  part  of  the  dog's  stomach  only 
corresponded  to  4  litres  of  gastric  juice  in  man  per 
diem. 

The  Capacity  of  the  Stomach. 

Different  authorities  give  very  varying  estimates 
of  the  capacity  of  the  human  stomach.  Beneke* 
gives  it  in  the  adult  as  2980  c.  cm.,  while  Ewald 
{Klinik  der  VerdaiLiingskrankheiten^  part  ii.)  states 
that  the  average  amount  which  the  stomach  can 
contain  is  little  over  a  litre,  although  1600  to  1700 
c.  cm.  may  often  be  held.  He  regards  3  pints  (1700 
cm.)  as  an  abnormal  quantity.  In  the  new-born 
infant  the  stomach  holds  only  36  c.  cm.,  or  about 
\\  oz.  ;  at  six  years  of  age  it  is  able  to  contain 
1090  c.  cm. ;  while  after  twenty  years  of  age  it 
reaches  its  maximum  capacity.  Although  these 
figures  are  the  means  of  many  observations,  we 
must  conclude  that  the  capacity  of  the  stomach 
varies  immensely  in  different   individuals,    and  that, 

*  Constitution  unci  Constitutions- Anotnalien.  d,  112. 


4  MEASUREMENTS    OF    STOMACH 

while  there  is  no  obvious  relation  between  its  size  and 
the  stature  of  the  person,  a  capacity  in  the  adult 
under  800  c.  c,  or  over  2000  c.  c,  must  be  considered 
to  be  abnormal. 

The  Measurements  of  the  Stomach. 

Sappey  gives  the  greatest  diameter  of  the  stomach 
from  left  to  right  as  24  to  26  cm.,  while  Vierordt 
gives  for  the  same  measurement  27  to  32  cm.  The 
diameter  from  the  lesser  to  the  greater  curvature 
is  10  to  12  cm.,  while  from  the  front  to  the  back 
it  is  8  to  9  cm.  These  figures  apply  to  the  stomach 
containing  food  ;  when  empty,  the  walls  are  closely 
applied  in  the  antero  -  posterior  direction,  and  its 
greatest  length  diminishes  to  18  to  20  cm.,  while 
the  distance  of  the  lesser  curvature  to  the  greater 
is  only  7  to  8  cm.  The  pylorus  is  i"8  cm.  distant 
from  the  cardiac  end  in  the  empty  stomach,  but 
after  food  only  14  cm.  from  it. 

Vierordt  gives  the  surface  of  the  gastric  mucous 
membrane  as  3000  cm. 

The  Gastric  Contents. 

In  practice  we  have  to  deal  with  the  contents  of  the 
stomach  after  the  ingestion  of  food.  These  vary  in 
composition  with  the  food  taken,  the  time  after  the 
meal,  and  the  state  of  health  of  the  individual.  That 
the  gastric  juice  secreted,  after  the  stimulation  of  the 
glands  by  the  constituents  of  the  food  swallowed,  is 
quite  different  in  composition  from  the  pure  juice  ob- 
tained after  mechanical  irritation  of  the  mucous  miem- 
brane,  is  shown  by  the  fact  that  the  gastric  contents 
generally  possess  a  very  much  higher  acidity  than  the 


GASTRIC    CONTENTS  5 

pure  juice  itself.  If  the  gastric  juice  were  secreted 
throughout  digestion  with  the  acidity  indicated  by 
analysis  of  the  fluid  obtained  in  the  manner  stated 
above,  the  acidity  of  the  gastric  contents  could  not 
rise  above  that  figure.  As,  however,  the  acidity 
rises,  and  rises  progressively  after  the  ingestion  of 
food,  the  amount  of  acid  formed  by  the  gastric 
glands  must  be  in  very  much  larger  proportion  to 
the  total  amount  of  fluid  secreted.  Samples  of 
the  stomach  contents  in  health  vary  in  composi- 
tion to  a  wide  extent,  and  the  results  obtained 
from  their  analyses  yield  little  information,  unless 
we  note  the  nature  of  the  meal  which  has  been 
taken,  and  the  time  after  it  at  ^vhich  the  sample 
has  been  removed. 

The  Three  Stages  of  G-astric  Digestion. 

We  may  look  upon  gastric  digestion  as  being 
divided  into  three  stages.  The  FIRST  STAGE  lasts 
from  fifteen  to  forty  minutes ;  in  it  the  acidity 
of  the  contents  is  always  rising,  but,  as  the  hydro- 
chloric acid,  which  is  being  secreted,  enters  into 
combination  with  the  salts  and  with  the  proteids  of 
the  food,  no  free  hydrochloric  acid  can  be  detected. 
This  stage  is  often  marked  by  the  presence  of  lactic 
acid  in  the  contents.  The  lactic  acid  may  be  con- 
tained in  the  food  itself,  or  arise  from  the  action 
of  micro-organisms  on  it.  As  the  acidity  is  chiefly 
composed  of  hydrochloric  acid  combined  with 
proteid  bodies,  it  exerts  only  a  weak  antiseptic 
action,  and  lactic  -  acid  -  forming  organisms  can 
flourish  unchecked.  In  THE  SECOND  STAGE  the 
hydrochloric    acid    is    still    being    secreted,    and    the 


6  STAGES    OF    GASTRIC    DIGESTION 

total  acidity  of  the  contents  continues  to  rise,  while 
free  hydrochloric  acid  can   now  be   detected.     That 
is    to    say,    that    more    hydrochloric    acid    is    being 
secreted  than  can  combine  at  once  with  the  proteids 
present.     The   antiseptic   action    of  the   free  hydro- 
chloric acid  checks  the  lactic  acid  fermentation,  and 
the  lactic  acid  soon  disappears.     The  THIRD  STAGE 
follows  after  the  maximum  acidity  has  been  attained, 
and  when  much  of  the  contents  of  the  stomach  have 
been  propelled  through  the  pyloric  orifice.     In  this 
stage  the  hydrochloric  acid,  combined  with  proteids, 
is  diminished  in  quantity ;  the  total  acidity  also  falls, 
while   there   is   a    much    larger    proportion    of    free 
hydrochloric   acid    present.     The   duration    of  these 
three  stages  varies  with  the  kind  of  food  taken.     If 
the  meal  be  largely  carbohydrate  in  nature,  the  first 
stage   is  very  short,  because   there   is    little   proteid 
material    with    which    the     hydrochloric    acid    can 
combine.     Free  hydrochloric    acid    soon    appears    in 
the    contents,  though  the  total  acidity  does  not  rise 
so  quickly.     The  second  stage  after  carbohydrate  food 
is  characterised  by  a    comparatively    larger    amount 
of  free  hydrochloric  acid,  a  total  acidity  which  is  not 
very  marked,  and  a  small  amount  of  acid  combined 
with  proteids.     The  first  stage  after  this  kind  of  food 
may  only  last  fifteen  minutes,  while  the  third  stage 
may  commence  as  soon  as  the  second  or  third  hour. 
On  the  other  hand,  if  the  meal  taken  be  composed 
largely  of  proteid  bodies,  free  hydrochloric  acid  may 
not  appear  in  the  contents  until  an  hour  has  elapsed. 
The  acidity   may  rise  to  a  high  point,  although  the 
free  acid  present  be  slight  in  amount,  the  bulk  of  it 
being  composed  of  acid  in  conjunction  with  proteid 


STAGES    OF    GASTRIC    DIGESTION  7 

bodies.  The  third  stage  after  such  a  meal — i.e.,  the 
stage  in  which  the  total  acidity  begins  to  fall  again — ■ 
may  not  be  reached  until  the  fourth  or  fifth  hour. 
A  mixed  diet  of  carbohydrates  and  proteids  leads  to 
conditions  midway  between  these  two  extremes. 

Periods  of  Healthy  Gastric  Digestion. 

1.  Fifteen  to  forty  minutes, — total  acidity  rising  ; 

lactic  acid  of  ten  present ;  free  hydrochloric  acid 
absent ;  hydrochloric  acid  combined  with  pro- 
teids the  chief  factor  in  acidity. 

2.  From  fifteen  or  forty  minutes    to   two   or   five 

hours, — after  carbohydrates  it  usually  begins 
early,  and  ends  by  the  third  hour.  Acidity 
rising ;  lactic  acid  absent,  or  only  in  traces ; 
free  hydrochloric  acid  present;  hydi'ochloric 
acid  combined  with  proteids  still  in  the  larger 
proportion ;  some  of  the  more  fluid  contents 
may  be  passed  through  the  pylorus. 

3.  From  two  or  five  hours  till  emptying  of  stomach 

at  the  end  of  three  to  six  or  seven  hours, — total 
acidity  falling  ;  free  hydrochloric  acid  present  in 
greater  proportion  ;  the  combined  acid  in  less; 
contents  are  being  expelled  through  the 
pylorus  more  rapidly. 

Of  course  we  must  remember  that  the  reaction  of 
the  food  taken  may  alter  the  characters  of  the 
stomach  contents  during  the  first  period  of  digestion, 
but  the  acids  in  food  -  stuffs  are  generally 
organic,  and  these  are  rapidly  absorbed  or  altered 
in    healthy    digestion,  and   have    little    influence    on 


5  STAY    OF    FOOD    IN    STOMACH 

its  course,  unless   they  are   present   in    large   quan- 
tities. 

Bearing  these  facts  in  mind,  we  can  easily  make 
out,  by  analysis  of  the  contents  of  the  stomach  in 
disease,  what  variation  from  the  normal  is  present,  if 
we  remember  that  the  sketch  of  the  processes  given 
above  does  not  apply  absolutely  to  all  cases,  but  that 
considerable  variations  even  in  health  may  occur. 

Duration  of  Stay  of  the  Food  in  the  Stomach. 

The  length  of  time  during  which  the  stomach  con- 
tents remain  in  that  organ  varies  with  the  nature  of 
the  food  taken.  Whatever  be  the  nature  of  the  food, 
it  is  probable  that  as  early  as  from  fifteen  to  twenty 
minutes  after  its  arrival  in  the  stomach  the  pyloric 
sphincter  temporarily  relaxes  and  allows  a  small  por- 
tion of  the  more  fluid  contents  to  escape.  This  action 
is  repeated  rhythmically  every  five  minutes  or  so, 
until  the  stomach  is  empty.  The  contents,  however, 
may  pass  through  the  pylorus  much  more  quickly, 
if  fluids  only  have  been  taken. 

The  more  solid  the  food  the  longer  does  it  remain, 
and  warmed  foods  pass  through  more  quickly  than 
cold. 

Schiile  found  that  300  c.  c.  water  at  18°  C.  passed 
through  the  stomach  of  the  dog  in  ten  minutes.  At 
a  temperature  of  0°  C,  fifteen  minutes  elapsed  before 
the  first  portion  passed  through  the  pylorus.  At  28°  C. 
and  40°  C.  its  passage  was  quickened.  Milk  passed 
through  almost  as  quickly  as  water.  Solids  mixed 
with  fluids  remained  longer,  the  fluid  portion  passing 
downwards  before  the  solids. 


STAY    OF    FOOD    IN    STOMACH  9 

The  flesh  of  animals  remains  from  two  and  a  half 
to  five  hours  in  the  stomach ;  lamb  about  two  hours 
and  a  half ;  beef,  mutton,  and  fish  three  hours  ;  veal 
and  pork  four  to  five  hours.  Soft  boiled  eggs  remain 
about  two  hours  and  a  half;  if  hard-boiled,  five 
hours. 

Vegetable  foods  remain  about  three  hours  in  the 
stomach. 

Fats  may  be  passed  on  early,  but  generally  remain 
to  the  last. 

Breakfast  may  be  said  to  take  four  hours  and  a 
half,  a  full  lunch  or  diimer  five  to  seven  hours,  and 
late  dinner  or  supper  seven  to  eight  hours,  before 
entirely  leaving  the  stomach. 

Ewald's  test-breakfast  should  only  remain  about 
two  hours  in  the  stomach,  Leube's  test-dinner  not 
longer  than  six  to  seven  hours. 

The  Contents  of  the  Pasting  Stomach. 

There  is  a  considerable  divergence  of  opinion  with 
regard  to  the  question  whether  the  healthy  stomach 
contains  any  fluid,  further  than  the  swallowed  saliva, 
when  more  than  seven  hours  have  elapsed  after 
the  ingestion  of  food.  Some  authorities  assert  that 
the  organ  is  absolutely  empty,  its  walls  covered  with 
mucus  possessing  an  acid  reaction  at  the  fundus, 
an  alkaline  at  the  pyloric  region.  Others  report  the 
presence  of  a  small  amount  of  fluid  ;  the  most 
reliable  observations  give  only  traces  of  hydrochloric 
acid,  never  more  than  0'004  per  cent. 

If  the  fasting  stomach  be  free  from  gases,  it 
forms  only  a  potential  cavity,  the  walls  being  closely 
applied  to  any  small  quantity  of  fluid  contained  in  it. 


lO  THE    FASTING    STOMACH 

In  this  condition  water  and  other  bland  fluids  pass 
almost  directly  into  the  duodenum. 

It  may  be  stated  here,  that  the  healthy  stomach, 
seven  hours  after  a  meal,  contains  little  fluid,  chiefly 
mucus  and  swallowed  saliva,  with  a  slightly  acid 
reaction.     No  free  hydrochloric  acid  is  present. 

The  mere  act  of  passing  a  stomach  tube  suffices  to 
call  forth  a  secretion  of  gastric  juice,  so  that  instances 
in  which  acid  material  has  been  obtained  by  its  use 
from  the  fasting  stomach  are  probably  fallacious. 


CHAPTER  II. 

THE  METHODS   FOR  OBTAINING  THE  CONTENTS 
OF  THE  STOMACH. 

Test-Meals — Methods  used  for  the  Withdrawal  of  the  Contents — The 
Stomach-Tube — How  to  pass  it — Stomach-Pumps — Expression 
— Einhorn's  Stomach-Bucket. 

In  dealing  with  this  subject  we  must  divide  our 
description  into  two  heads  : — First,  the  test-meals  ; 
second,  the  use  of  the  stomach-tube  and  other 
instruments. 

1.  Test-Meals. 

So  many  have  recommended  the  use  of  special 
test-meals  before  withdrawing  the  contents  of  the 
stomach  for  analysis,  that  it  is  necessary  here  to 
notice  the  principal  forms  suggested.  The  chief 
test-meals  in  use  are  as  follows  : — 

(«.)  Ezuald's  and  Boas'  Test  breakfast  (Probefriih- 
stuck).  In  this,  |  to  3  oz.  of  bread  are  given,  and 
from  10  to  13  oz.  of  weak  tea.  The  stomach  con- 
tents are  to  be  examined  an  hour  afterwards.  The 
ingredients  of  this  meal  are  designed  to  include 
albuminoids,  sugar,  starches,  non-nitrogenous  ex- 
tractives, and  salts ;  while  the  tea  belongs  to  a 
class  of  foods  which,  when  weak,  stimulate  the 
gastric  secretion. 


1 2  TEST-MEALS 

{b.)  Klemperer  suggests  that  a  pint  of  milk  be 
given  instead  of  the  tea,  along  with  the  same  amount 
of  bread,  and  that  the  contents  be  examined  two 
hours  afterwards.  The  substitution  of  the  milk  is 
recommended  in  order  to  subject  the  stomach  to  a 
severer  test. 

(^.)  Germain-See's  Test-meal. — This  consists  of  3  to 
5  o.z.  of  bread,  a  small  tumbler  of  water,  and  2  to 
2\  oz.  of  minced  meat.  The  stomach  contents  are 
to  be  examined  from  one  and  a  half  to  two  hours 
after  this  meal. 

(^.)  Bourgefs  Test-meal.^  —  Bourget  gives  300 
grains  of  toast  and  3  oz.  of  weak  tea  without 
sugar,  to  which  has  been  added  a  drachm  of 
tincture  of  mint.  The  disadvantage  of  this  meal 
is  that  it  contains  hardly  any  proteid,  and  it  is 
only  suitable  for  those  cases  in  which  the  secretion 
is  very  slow. 

(^.)  //"^rj-^/^^/Z recommends  a  lightly-boiled  Qgg,  i  oz. 
of  minced  meat,  3  oz.  of  toast,  and  a  quarter  of  a 
pint  of  very  weak  tea.  The  contents  should  be 
examined  one  and  a  half  hours  afterwards.  This 
test-breakfast,  it  is  evident,  contains  much  more 
proteid  matter  than  Ewald's. 

(/;)  Leiibe  and  Riegel  have  advocated  a  much 
larger  test-meal,  which  they  term  the  test-dinner 
(Probemittagsbrod).  It  consists  of  a  plate  of 
soup  (about  13  fluid  oz.),  60  grm.  (2  oz.)  of  scraped 
beef,  and  50  grm.  (if  oz.)  of  wheaten  bread.  This 
meal  contains  very  much  more  proteid  material,  and 
a  longer  time,  therefore,  must  elapse  before  the  con- 
tents  of  the   stomach    are    removed.      Indeed,  they 

*  La  Medecine  moderne^  August  4th,  1894. 


TEST-MEALS  1 3 

should  not  be  extracted  after  such  a  meal  until  four 
to  six  hours  have  elapsed. 

For  reasons  stated  above,  I  have,  for  my  own  part, 
found  it  quite  sufficient  to  remove  the  stomach 
contents  after  any  kind  of  meal,  the  nature  of  which 
is  known  and  which  approximates  more  nearly  than 
special  test-meals  to  the  ordinary  food  each  patient 
is  accustomed  to  take. 

Looking  at  these  test-meals  in  a  general  way, 
Ewald's  and  Bourget's  contain  hardly  any  proteid 
bodies — that  is  to  say,  they  give  the  stomach  little  of 
its  special  work — i.e.^  the  digestion  of  proteid  bodies — 
to  do.  It  appears  to  me  that  one  can  derive  more 
useful  information  regarding  the  chemistry  of  gastric 
digestion  if  the  stomach  contents  be  removed  after 
an  ordinary  meal  containing  a  fair  proportion  of  the 
proteids,  than  when  a  special  and  often  unac- 
customed form  of  food,  consisting  chiefly  of  carbo- 
hydrates and  water,  is  given.  In  the  latter  case, 
free  hydrochloric  acid  soon  appears  in  the  contents, 
owing  to  the  small  amount  of  albumin  with  which  it 
can  combine.  A  larger  meal,  such  as  Leube's  or 
Herschell's,  affords  us  evidence  of  how  far  gastric 
digestion  is  able  to  go  in  the  digestion  of  proteid 
bodies. 

In  addition  to  the  test-meals,  Leube  has  recom- 
mended the  washing-out  of  the  fasting  stomach  with 
400  c.  c.  of  lukewarm  water,  until  the  last  portions 
removed  are  neutral  to  litmus.  He  then  injects 
50  c.  c.  of  a  3  per  cent,  solution  of  soda,  which 
is  allowed  to  remain  in  the  organ  for  a  space  of 
about  twelve  minutes,  and  then  is  removed  again  by 
washing  out  the  stomach  with  400  c.  c.  of  water.     If 


14  TEST-MEALS 

at  the  expiration  of  twelve  minutes  the  soda  solution 
has  been  neutralised,  the  secretion  of  hydrochloric 
acid  is  normal ;  if  it  still  remains  alkaline,  the  secre- 
tion is  deficient. 

Still  another  method  has  been  used  by  Leube. 
He  injects  lOO  c.  c.  of  ice-cold  water  through  the 
tube  after  the  stomach  has  been  thoroughly  washed 
out.  After  ten  minutes  this  liquid  is  removed  by 
washing  out  the  organ  with  300  c.  c.  of  water,  and  its 
acidity  determined. 

The  last  two  methods,  however,  are  of  little 
practical  value,  as  it  has  been  shown  that  water 
rapidly  passes  through  the  stomach  and  excites 
little  secretion  of  acid.  In  the  first,  of  course,  the 
soda  may  excite  some  secretion,  but  the  knowledge 
gained  is  very  small. 

To  sum  up,  any  of  the  test-meals  described  above 
may  be  given,  or  the  patient  may  simply  take  what 
he  is  accustomed  to,  and  which,  as  a  rule,  experience 
has  shown  to  be  of  such  a  nature  as  is  most  easily 
digested  in  his  case,  and  to  cause  the  least  incon- 
venience. The  contents  should  be  removed  some  time 
after  the  meal.  The  lighter  the  meal  the  sooner  can 
the  stomach-tube  be  used.  If  unminced  meat  has 
been  taken,  three  or  four  hours  should  be  allowed  to 
elapse.  As  a  general  rule,  I  select  two  hours  after 
a  light  meal  for  the  process.  From  practical  experi- 
ence, milk,  I  find,  is  one  of  the  worst  foods  to  give 
before  trying  to  remove  the  contents  of  the  stomach. 
The  curdled  masses  clog  the  eyes  of  the  tube  more 
readily  than  other  foods. 


THE    STOMACH-TUBE  I  5 

2.  Methods  of  obtaining  the  Stomach  Contents. 

In  many  cases  of  dyspepsia,  where  the  diagnosis  is 
difficult  and  the  proper  treatment  depends  on  the 
nature  of  the  chemical  processes  in  the  stomach,  it 
is  often  imperative  to  obtain  some  of  the  material 
for  examination.  In  cases  in  which  this  is  not 
allowed  or  is  impossible,  chemical  analysis  of  the 
vomited  matter,  if  there  be  any,  may  afford  some 
clue  to  the  abnormal  processes  present.  But,  as 
in  the  act  of  vomiting  a  large  quantity  of  saliva  is 
secreted  and  mixes  with  the  stomach  contents,  the 
acidity  values  obtained  are  very  erroneous. 

The  easiest  way  to  obtain  the  contents  in  a  pure 
condition  is  by  the  use  of  the  ordinary  stomach- 
tube.  Obtaining  a  small  quantity  of  the  gastric 
contents  by  means  of  the  tube  is  a  much  less 
serious  proceeding  than  that  known  as  washing 
out  the  stomach.  Usually  a  sufficient  amount  of 
the  contents  can  be  obtained  immediately  on  pass- 
ing the  tube,  and  the  proceeding  may  only  occupy 
one  or  two  minutes. 

The  Stomach-Tulbe. 

The  stomach-tube  which  is  used  at  the  present 
day  is  made  of  red  rubber  of  a  moderately  soft 
consistence.  Two  forms  are  emplo}'ed :  one  with 
a  rounded  blind  extremity  and  two  lateral  eyes, 
one  placed  nearer  the  end  than  the  other.  The 
second  variety  has  an  open  end,  and,  in  addition, 
small  lateral  openings.  The  tube  with  the  rounded 
blind  end  is  to  be  preferred,  as  there  is  less  danger 
in  using  it  of  damaging  the  mucous  membrane  of 


I  6  THE    STOMACH-TUBE 

the  stomach  by  suction  into  the  lumen  of  the  tube 
through  the  terminal  opening.  The  sizes  generally 
employed  are  numbered  20  and  21  in  the  English 
scale  (see  Fig.  II.).  It  is  well  to  use  large  tubes  rather 
than  slender  ones,  as  the  muscles  of  the  pharynx 
grasp  a  large  tube  very  much  better  than  they  do  a 
slender  one,  and  thus  facilitate  its  progress  down 
the  oesophagus.  The  tube  should  be  from  32  to 
36  inches  long,  and  may  be  attached  by  means 
of  a  short  glass  tube  to  a  further  length  of  rubber 
tubing.  Care  must  be  taken  that  the  piece  of  glass 
inserted  between  the  two  rubber  portions  of  the  tube 
is  so  made  that  the  junctions  between  it  and  the 
stomach-tube  are  firm.  There  is  just  a  chance  that 
if  the  stomach-tube  became  detached  it  might  slip, 
down  bodily  into  the  stomach.  At  the  other  end 
of  the  upper  rubber  tube  a  funnel  of  moderate  size  is 
inserted.  If  the  operation  is  to  take  place  at  the 
practitioner's  house,  a  glass  funnel  is  preferable,  but 
when  performed  at  the  patient's  house,  a  vulcanite 
or  enamelled  one  is  better. 

The  first  thing  that  should  be  done  is  to  give 
the  patient  a  pledget  of  cotton  wool  soaked  in  a 
5  per  cent,  cocaine  solution,  directing  him  to  suck 
this  and  to  keep  the  saliva  and  the  cocaine  as  long 
as  possible  about  the  back  of  the  mouth.  Cocaine 
takes  several  minutes  to  act  in  many  individuals, 
and  it  is  better  to  wait  for  at  least  five  minutes 
before  attempting  to  introduce  the  tube.  While 
the  cocaine  is  acting  the  other  necessary  arrange- 
ments can  be  prepared.  The  patient  is  placed  on  a 
chair  which  may  be  put  on  the  centre  of  a  large 
square  of  waterproof  sheeting.     A  piece  of  macintosh 


PASSAGE    OF    STOMACH-TUBE  1 7 

is  fastened  over  his  clothes  ;  while  he  is  directed  to  sit 
with  his  knees  wide  apart,  so  that  anything  spilt 
on  the  macintosh  runs  into  a  pail,  which  should 
be  placed  on  the  floor  between  them.  The  tube 
is  often  directed  to  be  moistened  with  glycerine 
or  with  oil,  but  patients  often  dislike  the  taste  of  the 
oil,  while  the  glycerine  may  irritate  the  pharynx. 
I  prefer  simply  to  dip  the  tube  in  warm  water. 
Then,  asking  him  to  throw  his  head  slightly  back, 
the  point  of  the  tube  is  introduced  over  the 
tongue  into  the  pharynx.  It  is  as  well,  especially 
on  the  first  occasion,  to  allow  it  to  remain  there 
for  a  short  time,  while  the  patient  is  directed  to 
breathe  through  his  nose,  and  to  swallow  any  saliva 
that  may  be  present.  The  point  of  the  tube  is 
then  gently  pressed  downwards  and  the  patient 
requested  to  swallow.  The  muscles  of  the  pharynx 
catch  the  tube,  and  no  difficulty  will  then  be  experi- 
enced in  passing  it  right  down  into  the  stomach. 
If  the  patient  at  any  time  expresses  a  fear  of  being 
suffocated,  direct  him  to  breathe  freely  through  the 
nose,  stopping  at  the  same  time  the  progress  of  the 
tube. 

When  the  point  of  the  tube  has  entered  the 
stomach  cavity  there  is  usually  an  escape  of  gas. 
As  a  rule,  if  the  operation  be  performed  two  or 
three  hours  after  a  meal,  no  difficulty  will  be 
encountered  in  obtaining  some  of  the  contents 
through  the  tube  for  examination.  If  the  patient 
be  directed  to  retch,  on  almost  all  occasions  some 
of  the  contents  will  pass  up  the  tube  and  can  be 
caught  in  a  clean  vessel.  Whenever  it  is  certain 
that  the   end  of  the  tube  has  reached  the  stomach, 

B 


15  PASSAGE    OF    STOMACH-TUBE 

the  funnel  at  the  free  end  should  be  depressed,  so 
that,  if  the  action  of  retching  be  sufficiently  strong 
to  force  some  of  the  contents  even  a  little  beyond 
that  part  of  the  tube  which  projects  out  of  the 
mouth,  syphon-action  may  take  place.  If  the 
patient's  own  exertions  are  not  sufficient  to  force 
some  of  the  contents  through  the  tube,  the  opera- 
tion of  "  expression "  may  be  performed,  as  first 
suggested  and  performed  by  Ewald.  This  operation 
simply  means  the  application  of  pressure  over  the 
region  of  the  stomach,  the  patient  bending  forward 
at  the  time,  by  which  means  the  contents  may  often 
be  forced  with  great  ease  through  the  stomach-tube. 
The  pressure  may  be  applied  by  the  operator  or 
by  the  patient  himself  If,  before  a  sufficient 
quantity  of  the  contents  have  been  obtained,  a 
blockage  of  the  lumen  occurs  and  no  more  will 
pass  through  the  tube,  it  may  be  M'ithdrawn  for  an 
inch  or  so  and  then  passed  back  again.  After  this 
the  obstruction  generally  disappears.  If  none,  or 
too  little,  of  the  contents  can  be  obtained  in  this 
way,  a  method  which  I  have  found  very  valuable 
may  be  tried, — i.e.,  fill  the  funnel  with  warm  water, 
pinching  the  india-rubber  tube  a  short  distance 
below  with  the  left  hand,  so  that  no  air  can  get 
down  ;  then  relaxing  the  pressure,  let  the  water  fill  the 
tube  to  some  way  beyond  the  piece  of  glass  inserted 
in  the  middle  of  it.  Then,  Avhen  just  enough  water 
has  been  allowed  to  pass  down  to  fill  the  tube,  lower 
the  funnel,  let  the  water  run  into  the  pail,  and  the 
contents  of  the  stomach  are  sucked  up  by  the 
syphon-action  thus  induced,  and  may  be  caught, 
when  they  appear  after  the  water,  in  a  clean  basin 


PASSAGE    OF    STOMACH-TUBE  1 9 

held  for  the  purpose.  If  it  is  done  carefully,  little 
or  no  water  enters  the  stomach,  and  hence  the  con- 
tents are  not  diluted. 

If  all  these  operations  are  resultless,  some  warm 
water  must  be  poured  down  the  tube  into  the  stomach, 
and,  after  a  certain  quantity  has  been  administered — 
the  arriount  should  be  measured  beforehand — and 
before  all  the  water  has  left  the  funnel,  it  should  be 
rapidly  depressed  and  the  syphon-action  started. 
The  quantity  of  contents  obtained  will  indicate,  know- 
ing as  we  do  the  amount  of  water  added,  what  pro- 
portion the  pure  contents  bear  to  the  total  fluid. 

In  withdrawing  the  tube  care  should  be  taken  that 
it  is  not  pulled  up  too  quickly.  There  is  a  danger 
also,  if  the  stomach  has  been  emptied  and  if  some 
fluid  still  remains  in  the  tube,  of  the  mucous  mem- 
brane being  injured  by  suction  of  a  part  of  it  into  the 
openings  at  the  end  of  the  tube.  It  is  as  well  to 
pour  in  a  small  quantity  of  water  with  the  funnel 
raised  before  withdrawing  the  tube,  and  then,  without 
depressing  the  funnel,  to  carefully  pull  it  up,  as  the 
increased  pressure  forces  the  mucous  membrane 
away  from  the  eyelets. 

After  removing  the  tube  it  should  be  well  washed 
in  cold  water,  allowing  a  stream  to  pass  through  its 
lumen,  to  clear  out  the  openings  at  its  end  ;  then  it 
may  be  washed  in  warm  water,  in  a  solution  of 
carbolic  acid,  and  in  warm  water  again,  dried,  and 
put  away,  lying  as  fully  extended  as  possible.  Before 
using  it,  it  should  again  be  washed  in  warm  water,  to 
clean  it  and  render  it  more  pliable. 


20  STOMACH-PUMPS 

Stomach-Pumps. 

Boas  has  devised  a  useful  form  of  the  ordinary 
india-rubber  ball-pump,  in  which  a  valve,  placed 
between  the  stomach-tube  and  the  cavity  of  the 
pump,  allows  the  stomach  contents  to  be  readily 
withdrawn  and  emptied  into  a  vessel  (see  Fig.  III.). 
The  ordinary  medical  aspirator,  such  as  is  generally 
used  for  tapping  any  of  the  body  cavities,  may  be 
attached  to  a  stomach-tube,  the  end  of  the  stomach- 
tube  being  joined  to  the  inlet  of  the  vacuum  bottle.  It 
is  better,  however,  if  possible,  to  avoid  the  use  in  all 
cases  of  any  force  when  withdrawing  the  contents. 

Expression. 

This  method  only  requires  incidental  notice,  as  it 
has  been  mentioned  above.  Boas  and  Herschell 
recommend  it,  as  a  simpler  and  more  useful  way  of 
obtaining  some  of  the  stomach  contents  than  by 
syphonage  or  aspiration.  Boas,  indeed,  prefers  to 
express  the  contents  of  the  stomach  than  to  wash 
out  the  organ  in  the  ordinary  way.  To  express 
the  contents  of  the  stomach  the  tube  is  passed  in, 
pressure  applied  over  the  gastric  region,  or  the 
patient  is  directed  to  cough. 

Einiiorn's    Stomach-Bucket. 

Einhorn  has  invented  an  instrument  which  he 
terms  the  stomach-bucket  (Fig.  IV.).  By  means  of 
this  instrument  a  small  quantity  of  the  stomach  con- 
tents can  be  easily  removed  and  analysed. 

A  bucket  of  silver,  with  an  opening  at  its  upper 
extremity,  is  attached  to  a  silk  thread.     The  thread 


Fig.  3.— Boas's  Ball-pump.     (See  page  20.) 


Fig.  4. — Einhorn's  Stomach  Bucket.    (See  page  20.) 


STOMACH-BUCKET  2  I 

bears  a  knot  or  mark  i6  inches  from  the  bucket, 
serving  as  a  guide  as  to  the  entrance  of  the  bucket 
into  the  stomach.  The  bucket  is  placed  far  back  on 
the  tongue  and  the  patient  told  to  swallow  it.  In 
one  or  two  minutes  it  reaches  the  stomach,  and 
should  be  left  there  for  five  minutes.  In  withdraw- 
ing it,  if  any  difficulty  be  felt  as  it  passes  the  cardiac 
orifice,  the  patient  is  instructed  to  swallow,  and  the 
thread  drawn  up  at  the  same  time.  If  there  be  much 
mucus  in  the  oesophagus,  the  bucket  may  become 
filled  with  it,  and  not  with  the  gastric  contents.  To 
guard  against  this,  a  thin  gelatinous  covering  may  be 
stretched  over  the  opening,  as  this  covering  rarely  be- 
comes dissolved  before  reaching  the  stomach  cavity. 
The  best  time  to  use  the  bucket  is  one  hour  after 
Ewald's  test-breakfast,  or  later  if  a  larger  meal  has 
been  taken.  The  quantity  of  stomach  contents 
which  can  be  obtained  by  the  stomach-bucket  is  so 
small  that  its  use  is  inadvisable  unless  in  the  case  of 
a  patient  intolerant  of  the  tube. 

The  stomach-tube  or  bucket  should  not  be  made  use 
of  in  the  examination  of  patients  suffering  from  a 
thoracic  aneurism,  severe  heart  disease,  or  any  debili- 
tating disease  tending  to  the  occurrence  of  syncope  ;  in 
old  people  as  a  rule,  or  in  advanced  cancer  of  the 
stomach  or  gastric  ulcer  with  recent  hsemorrhage. 


CHAPTER  III. 

THE    EXAMINATION    OF   THE    FLUID    REMOVED 
FROM  THE  STOMACH,  OR  OF  THE  VOMIT. 

Macroscopic  Examination  :  Appearance — Amount — Specific  Gravity — 
Smell — Undigested  Food — Mucus — Blood — Pus.  Microscopical 
Examination  :  Pus  Cells — Blood-Corpuscles — Micro-organisms — 
Cancer  Cells — Residual  Remains. 

Macroscopic  Examination. 

I.  Naked-Eye  Appearance. — The  colour  and  the 
character  of  the  solids  in  the  fluid  are  first  noted. 
It  is  as  well  to  allow  the  unfiltered  contents  to  stand 
for  some  time  before  noting  the  appearance.  They 
usually  separate  into  two  layers,  the  lower  containing 
the  solids,  the  upper  the  fluid  portion.  If  the 
digestive  powers  of  the  stomach  are  good,  the  solid 
matter  is  in  small  particles,  the  fluid  portion  almost 
clear.  The  contents  removed  from  a  dilated  stomach 
often  present  a  peculiar  and  easily  recognised 
appearance.  The  solids  separate  into  two  layers, 
one  at  the  bottom  of  the  vessel,  the  other  floating  on 
the  surface,  with  a  dividing  layer  of  fluid  between. 
The  upper  layer  of  solid  matter  is  like  scum,  and 
grey  or  brownish  in  colour,  and  consists  chiefly  of 
sarcinae  and  yeasts.  On  other  occasions  the  contents 
from  such  cases  are  porridgy  and  fermented.  If  the 
food  taken  consist  of  highly-coloured  substances  the 


EXAMINATION    OF    GASTRIC    CONTENTS  23 

contents  exhibit  a  corresponding  tint.  In  general 
they  are  of  a  pale  whitish-yellow,  or  darker  yellow- 
grey  hue. 

2.  Amount. — The  amount  of  food  vomited  or  with- 
drawn varies  with  the  size  of  the  previous  meal  and 
the  time  after  it  has  been  taken  in  healthy  persons, 
or  in  those  who  suffer  only  from  a  temporary  acute 
attack  of  dyspepsia. 

From  one  to  two  pints  is  not  an  abnormal  quantity, 
unless  obtained  or  vomited  more  than  five  hours 
after  a  light  meal,  or  six  or  seven  hours  after  a 
full  one.  In  cases  of  dilated  stomach  enormous 
quantities  are  sometimes  present.  Thus  Ewald  refers 
to  a  case  in  which  as  much  as  8  kilogrammes  (17I 
pounds)  of  material  is  said  to  have  been  vomited ! 
In  acute  gastritis  the  quantity  vomited  is  often 
moderate  in  degree,  but  is  peculiar  in  that,  however 
fluid  the  previous  meal  has  been,  the  vomit  is  nearly 
always  thick  and  porridgy. 

When  vomiting  of  large  quantities  of  fluid  occurs 
long  after  the  taking  of  food,  or  when  similar 
quantities  can  be  removed  by  means  of  the  tube 
before  breakfast  in  the  morning,  stagnation  of  the 
stomach  contents  is  present  with  delayed  emptying. 
If  the  fluid  obtained  in  the  morning  contain  a 
normal  or  an  increased  amount  of  hydrochloric  acid, 
often  without  more  than  traces  of  food,  the  condition 
of  hypersecretion  of  the  gastric  juice  is  present. 
In  this  the  amount  removed  before  breakfast  may 
be  large.  In  cirrhosis  of  the  stomach  walls  very 
little  fluid  may  be  obtainable ;  a  total  capacity  of  as 
little  as  4  oz.  has  been  observed. 


24         EXAMINATION    OF    GASTRIC    CONTENTS 

It  should  be  mentioned  that  many  (Schreiber, 
Rosin,  Leo,  and  Kinnicutt")  maintain  that  from  2  to 
50  c.  c.  (I  dr.  to  if  oz.)  can  be  obtained  from  the 
healthy  fasting  stomach,  and  that  this  fluid  contains 
free  hydrochloric  acid.  The  investigations  of  Ewald, 
Boas,  and  Rosenheim  discredit  this  observation,  and 
support  the  previous  results  of  Gmelin  and  Tiede- 
mann  (1826),  who  could  find  no  trace  of  gastric  juice 
when  fasting.  The  former  observers  were  probably 
misled  by  a  secretion  occasioned  by  the  passage  of 
the  stomach-tube. 

3.  Specific  Gravity  of  the  Filtered  Con- 
tents.— The  normal  specific  gravity  of  pure  gastric 
juice  is  from  1002  to  1005. 

The  contents  removed  six  to  seven  hours  after 
a  meal  have  a  specific  gravity  of  1004  to  1006, 
and  of  1007  in  any  fluid  removed  before  break- 
fast* 

After  meals  it  rises  to  from  loio  to  1020;  when 
the  contents  are  hyperacid,  or  the  seat  of  acid 
fermentation,  it  is  lOio;  in  hypoacidity,  1020.  Any 
figure  above  1020  indicates  hypoacidity. 

The  variations  in  the  specific  gravity  depend 
chiefly  on  the  amount  of  sugar  present,  and  only 
slightly  on  the  quantity  of  fluid  taken  at  the  previous 
meal,  except  for  a  short  time  after,  owing  to  the 
rapidity  with  which  any  excess  of  fluid  is  got  rid  of 
through  the  pylorus,  unless,  indeed,  motor  activity 
be  impaired.  In  hypoacidity,  with  no  free  hydro- 
chloric acid  during  the  early  stages  of  digestion, 
conversion   of    starch  into    maltose  can  continue  to 

'•■  Strauss,  Zeitschrift  f.  klin.  Med.,  xxix.,  H.   3,  4. 


EXAMINATION    OF    GASTRIC    CONTENTS  25 

take  place    in    the    stomach,   thereby   increasing    the 
specific  gravity  of  the  filtered  contents. 

4.  Smell. — In  healthy  gastric  digestion  the  stomach 
contents  possess  a  peculiar  "  gastric  "  smell.  In  all 
cases  with  fermentation  they  are  characterised  by  a 
disagreeable  or  sour  odour.  The  odour  of  fluid  from 
a  dilated  stomach  with  great  stagnation  is  especially 
disagreeable.  If  the  smell  be  like  that  of  rancid  fat, 
butyric  acid  fermentation  has  been  in  progress  ;  if 
like  sour  milk,  lactic  acid  formation  ;  or  if  like 
vinegar,  acetic  acid  has  resulted  from  bacterial 
action.  In  rare  instances  there  may  be  a  smell  of 
sulphuretted  hydrogen  or  of  putrefactive  changes, 
due  to  decomposition  of  proteids. 

5.  Undigested  Food. — The  presence  or  absence 
of  undigested  portions  of  food  should  be  noted.  The 
character  of  the  food  taken,  and  sometimes  the 
period  of  time  which  has  elapsed  without  emptying 
of  the  stomach,  may  be  ascertained  by  the  nature  of 
the  fragments  found,  such  as  fruit  skins,  orange  pips, 
coagula  of  milk,  undigested  muscle,  etc. 

The  undigested  muscle  fibres  may  be  recognised 
under  the  microscope,  while  the  presence  of  lumps  of 
still  undigested  meat  in  contents  removed  three  or 
four  hours  after  a  meal  shows  that  the  digestive 
power  of  the  stomach  is  diminished. 

The  diagnosis  between  regurgitation  of  food  from 
an  oesophageal  diverticulum  and  vomiting  from  the 
stomach  may  depend  to  some  extent  on  the  state  of 
the  muscle  fibres  should  they  be  present  in  the  fluid 
ejected. 


26         EXAMINATION    OF    GASTRIC    CONTENTS 

6.  Mucus. — An  excess  of  mucus  is  easily  re- 
cognised by  the  naked  eye.  The  stringy  and 
gelatinous  nature  of  the  stomach  contents  serves  to 
indicate  its  presence  in  undue  quantity.  Normally 
it  amounts  to  only  half  a  teaspoonful.  It  is  in  larger 
quantity  in  vegetable  eaters  than  in  those  who  chiefly 
live  on  meat.* 

Some  of  the  gelatinous  material  may  be  placed  in 
cold  water  and  gently  washed  in  it.  The  water  is 
then  poured  off  and  a  little  liquor  potassae  or  baryta 
water  added.  The  mucus  dissolves  in  this,  and  can 
be  precipitated  from  the  solution  by  acetic  acid,  in 
which  it  is  insoluble  in  excess. 

The  mucus  is  generally  colourless,  but  may  be 
slightly  pigmented  in  long-standing  cases  of  chronic 
gastric  catarrh.  As  a  rule  pigmented  mucus  in  the 
vomit  comes  from  the  lungs.  The  mucus  contained 
in  the  gastric  contents  removed  by  the  stomach-tube 
must  come  from  the  stomach  itself,  or  from  the 
saliva  which  has  been  swallowed. 

When  the  gastric  juice  is  of  normal  activity 
microscopical  examination  of  some  of  the  mucus 
shows  that  only  the  nuclei  of  the  cells  entangled  in 
it  remain  (Jaworski).  If  digestion  be  weak  the 
cells  are  entire.  Jaworski's  "  spiral "  bodies,  formed 
from  mucus  by  free  hydrochloric  acid,  may  also  be 
discovered. 

Mucus  is  increased  in  acute  inflammatory  affec- 
tions of  the  gastric  mucous  membrane,  and  in 
cases  of  hyperchlorhydria  and  gastric  ulcer.  In 
cases  such  as  the  last  two,  where  the  hydrochloric 
acid   is   increased   in    amount,    the   mucus    is    often 

*  Schmidt,  Deiitsch.  Arch.f.  klin.  Med.,  Ivii.  I,  2. 


EXAMINATION    OF    GASTRIC    CONTENTS  2/ 

present  in  the  form  of  balls  or  threads.  In  atrophy 
of  the  mucous  membrane  and  in  cancer  of  the  pylorus 
and  walls  of  the  stomach,  in  which  hydrochloric 
acid  is  diminished  or  absent,  the  secretion  of  mucus 
is  increased. 

7.  Blood. — If  the  bleeding  is  profuse  and  from 
an  artery,  the  blood  may  be  bright^  and  either  clotted 
or  capable  of  clotting.  When  it  has  remained  in 
the  stomach  for  a  short  time  it  comes  up  in  dark 
clots,  while  if  it  has  remained  for  a  long  time  the 
blood  is  altered  to  a  dark  brown  or  black  material, 
like  "coffee-grounds,"  which  is  not  in  the  form  of 
clots,  nor  does  it  clot  outside  the  body. 

When  the  haemorrhage  has  been  slight,  it  is  often 
difficult  to  determine  whether  the  lungs  or  the 
stomach  are  at  fault.  As  a  general  rule  blood 
which  has  come  from  the  lungs  or  air  passages  is 
bright  in  colour,  while  blood  from  the  stom.ach  is 
darker. 

When  present  in  small  quantity,  the  discovery  of 
blood-corpuscles  under  the  microscope  decides  the 
question.  Indeed,  microscopical  examination  some- 
times reveals  its  presence  when  no  naked-eye 
evidence  is  obtainable.  The  well-known  guaiacum 
and  ozonic  ether  test  is  not  of  much  use  in  testing 
for  blood  in  the  stomach  contents,  as  many  of  the 
common  vegetable  constituents  of  the  food,  as  well 
as  saliva  and  bile,  respond  to  it. 

When  the  blood  has  been  vomited  in  the  form  of 
"  coffee-grounds,"  the  microscope  affords  us  no  assist- 
ance. As  the  same  appearance  may  be  presented 
by  the  entrance  of  bile   into   the   stomach,  or  by  an 


2  8  EXAMINATION    OF    GASTRIC    CONTENTS 

admixture  of  tea  or  coffee  taken  shortly  before,  it 
is  often  necessary  to  determine  the  nature  of  the 
''  grounds." 

Bile  can  be  identified  by  the  play  of  colours  with 
fuming  nitric  acid  (Gmelin's  test). 

If  the  deposit  be  formed  of  altered  blood,  in  which 
the  haemoglobin  is  changed  into  insoluble  haematin, 
two  tests  will  reveal  the  fact  : — 

(«.)  The  formation  of  hsemin  crystals,  by  placing 
a  small  drop  of  the  deposit  on  a  microscope  slide, 
adding  a  crystal  of  chloride  of  sodium  and  a  drop 
of  glacial  acetic  acid,  then  covering  with  a  cover- 
glass,  and  heating  over  a  spirit  lamp  until  bubbles 
commence  to  form.  Under  the  microscope,  small 
reddish-brown  oblique  rhombic  crystals  of  the 
hydrochlorate  of  haemin  can  be  seen  if  blood  pig- 
ment is  present. 

{b.)  By  the  formation  of  Prussian  blue,  signifying 
the  presence  of  iron.  For  this  test  to  be  of  moment 
the  patient  must  not  be  taking  any  preparation  of 
iron. 

A  small  quantity  of  the  black  deposit  is  mixed 
with  a  little  chlorate  of  potassium  in  a  capsule,  and 
a  drop  or  two  of  hydrochloric  acid  added.  The 
mixture  is  heated  over  a  spirit  lamp,  and  a  few  drops 
of  a  5  per  cent,  solution  of  potassium  ferrocyanide 
added.     If  blood  is  present,  Prussian  blue  is  formed. 

The  presence  of  blood  in  large  amount  indicates 
gastric  ulcer  or  carcinoma,  the  former  especially  if  it 
be  bright  in  colour.  Lesser  quantities  may  come 
from  the  stomach  in  similar  conditions,  and  also  in 
erosions  of  the  mucous  membrane,  congestion  of  the 
liver,  and  acute  gastritis.     In  the  latter,  and  in  some 


EXAMINATION    OF    GASTRIC    CONTENTS  29 

cases  of  chronic  catarrh,  the  presence  of  blood  can 
only  be  discovered  by  the  identification  of  the  red 
corpuscles  under  the  microscope.  Blood  also  may 
be  contained  in  the  contents  voided  in  cases  of 
phlegmonous  gastritis,  and  when  congestion  of  the 
stomach  is  caused  by  backward  pressure  from  heart 
disease  or  cirrhosis  of  the  liver. 

8.  Pus. — Pus  may  be  present  in  the  gastric  con- 
tents, and  is  usually  due  to  muco-pus  brought  up 
from  the  air  passages  and  mixed  with  the  vomit. 
It  may,  however,  be  due  to  phlegmonous  gastritis, 
with  localised  abscesses  of  diffuse  suppuration.  It 
is  easily  recognised  under  the  microscope. 

Microscopical   Examination. 

The  identification  of  pus  cells  and  blood  corpuscles 
by  means  of  the  microscope  has  already  been  referred 
to,  and  mention  made  of  the  value  of  this  method 
in  the  detection  of  undigested  muscle  fibres,  and  in 
deciding,  from  the  appearances  presented  by  detached 
epithelial  and  other  cells,  upon  the  activity  of  the 
contents  before  removal.  If  they  are  entire,  the 
digestive  power  is  weak ;  if  nuclei  alone  remain,  it  is 
active. 

It  will  aid  in  the  diagnosis  of  the  nature  of  any 
fermentative  process  present  if  the  form  of  organ- 
ism contained  in  the  fluid  can  be  identified.  Cover- 
glass  preparations  can  be  made  directly  from  the 
specimen  and  mounted  unstained,  or  after  staining 
with  methylene  blue. 

Sarcina  ventriculi  and  yeasts  take  up  aniline  dyes 


30  BACTERIA    IN    STOMACH    CONTENTS 

very  readily,   and    the  excess  must  be  removed  by 
washing  before  examination. 

With  iodine  and  weak  sulphuric  acid,  the  sarcina 
ventriculi  gives  a  red-violet  colour,  the  cellulose 
reaction. 

In  addition  to  these  forms,  various  moulds  may  be 
present,  and  several  species  of  bacteria,  bacilli,  and 
micrococci. 

The  bacterial  forms  may  be  divided  into  two 
classes  : — (i),  Those  which  form  acids  by  their  growth, 
and  which,  as  a  rule,  do  not  liquefy  gelatine  ;  and 
(2),  those  giving  the  medium  in  which  they  grow  an 
alkaline  reaction,  and  which  generally  liquefy  gelatine. 

To  the  first  class  belong  Bacillus  Coli  Communis, 
Bacillus  Acidi  Lactici,  Bacterium  Lactis  Aerogenes, 
which  do  not  liquefy  gelatine,  and  Bacillus  Butyricus 
and  Bacillus  Amylobacter,  which  do. 

In  the  second  class  are  found  Bacillus  Subtilis, 
Proteus  Vulgaris,  and  Bacillus  Fluorescens  Lique- 
faciens. 

In  addition,  several  micrococci  and  leptothrix 
forms  have  been  identified. 

The  presence  of  cells  from  malignant  growths,  and 
of  small  detached  portions  of  the  gastric  mucous 
membrane,  can  also  be  determined  by  use  of  the 
microscope. 

An  examination  of  the  precipitate  from  a  speci- 
men of  stomach  contents,  which  has  been  removed 
from  the  paper  used  for  its  filtration  or  obtained  from 
the  deposit  present  on  standing,  often  throws  con- 
siderable light  on  the  nature  of  the  processes  present. 

As  already  mentioned,  the  digested  or  undigested 
state  of  the  muscle  fibres,  and  the  presence  of  entire 


CELLS  IN  STOMACH  CONTENTS       3 1 

epithelial  cells,  or  of  their  nuclei  only,  may  afford  a 
means  for  the  determination  of  the  peptic  activity  of 
the  fluid  examined.  Connective  tissue  fibres  and 
elastic  fibres  may  be  recognised,  and  fat  globules, 
starch  granules,  and  vegetable  cells  found  in  the 
deposit. 


CHAPTER  IV. 

THE  EXAMINATION  OF  THE  FLUID  REMOVED 
FROM    THE    STOMACH,    OR    OF    THE  VOMIT— 

(Continued). 

THE  CHEMICAL  EXAMINATION. 

The  Total  Acidity — Deci-normal  Solutions — Qualitative  Tests  for 
Free  Acids — Fi^ee  Acids  of  any  Kind- — Congo  Red — Tropaeolin — 
Benzo-purpurin — Leo's  Test — Free  Hydrochloric  Acid — Vanillin- 
Phloroglucin  (Giinzburg's) — Resorcin  (Boas') — Sulphocyanide  of 
Potassium  (Mohr's)  for  Free  Organic  Acids — Uffelman's  Re- 
agent— Perchloride  of  Iron — Boas'  Aldehyde  Test — Formation  of 
Ethers — Cacodyl — Strauss'  Method  of  'applying  the  Perchloride 
of  Iron  Test. 

1.  Total  Acidity. 

In  every  case  the  first  of  the  more  minute  analyses 
should  be  the  estimation  of  the  total  acidity  of  the 
contents.  This  total  acidity  comprises  the  acidity 
due  to  acid  salts,  and  to  mineral,  and  organic 
acids,  in  a  free  state  or  combined  with  proteids,  which 
are  present.  The  contents  may  be  tested  before  or 
after  filtration.  The  acidity  values  obtained  before 
and  after  the  contents  have  been  filtered  very  often 
vary  greatly.  If  the  proteids  are  in  undigested 
masses,  some  of  the  acid  present  combines  with 
them ;  after  filtering,  this  combined  acid  remains 
behind  on  the  filter  paper  with  the  proteid,  and  the 


TOTAL    ACIDITY  33 

acidity  of  the  filtrate  is  below  that  of  the  original 
specimen.  If  there  is  little  free  acid  the  acidity  of 
the  filtrate  may  be  much  lower  than  that  of  the  un- 
filtered  contents.  On  the  other  hand,  if  the  contents 
are  largely  composed  of  insoluble  vegetable  bodies,  the 
filtrate  may  have  a  higher  acidity  than  before  filtration. 
As  noted  above,  the  total  acidity  varies  with  the  time 
after  food  has  been  taken,  with  the  nature  of  that 
food,  and  with  the  individual  from  whom  it  has  been 
obtained.  The  total  acidity  rarely  reaches  0'3  per 
cent.  Schiile  gives  it  as  O'li  to  0"26  per  cent.,  while 
Hayem  and  Winter  give  the  normal  limits  as  0"i8  to 
0'2  per  cent.  Shortly  after  food  the  amount  may 
be  very  much  less  than  this,  while  three  or  four  hours 
after  a  meal  largely  consisting  of  proteids,  it  may  rise 
to  0"4  per  cent,  without  indicating  the  presence  of 
any  diseased  condition. 

The  question  whether  the  contents  are  acid  or  not 
may  be  at  once  answered  by  the  use  of  blue  litmus 
paper,  which  reacts  both  to  acid  salts  and  to  acids 
themselves.  But  a  qualitative  estimation  of  the 
reaction  is  seldom  of  much  service.  To  arrive  at  a 
knowledge  of  the  exact  acidity  present  we  must  use 
another  test.  For  this  a  deci-normal  solution  of  caustic 
soda  is  necessary.  A  normal  solution  is  one  of  which 
a  litre  contains  the  exact  weight  in  grammes  of  the 
chemical  body  used  which  corresponds  to  its  molecular 
weight.  That  is  to  say,  a  normal  solution  of  sodium 
hydrate  contains  40  grm.  Na.  in  the  litre  of  distilled 
water  (NaHO  =  23,  H  =  i,  0—16).  A  deci-normal 
solution  is  a  normal  solution  diluted  ten  times,  while 
a  centi-normal  solution,  which  may  be  used  when 
great  accuracy  is  desired,  fs  a  normal  solution  diluted 

C 


34  TOTAL    ACIDITY 

a  hundred  times.  A  given  quantity  of  a  normal 
solution  of  any  alkali  will  exactly  neutralise  the  same 
amount  of  a  normal  solution  of  an  acid.  Thus, 
lOO  c.  c.  of  normal  soda  solution  will  neutralise  lOO 
c.  c.  of  a  normal  solution  of  hydrochloric  acid  ;  and  as 
hydrochloric  acid  has  a  molecular  weight  of  36'5, 
lOO  c.  c.  of  normal  soda  corresponds  to  3"65  grm.  of 
this  acid.  When  the  acid  is  dibasic,  as,  for  instance, 
in  the  case  of  sulphuric  acid,  only  half  of  the  sum  of 
the  molecular  weight  is  used  in  making  up  the  normal 
solution.  Sulphuric  acid  has  a  molecular  weight  of 
98,  and,  therefore,  49  grm.  of  the  acid  are  added  to 
each  litre  to  make  up  a  normal  solution.  In  the 
same  way,  oxalic  acid  with  a  molecular  weight  of  126 
only  requires  63  grm.  to  the  litre  to  form  a  normal 
solution.  A  litre,  then,  of  a  deci-normal  solution  of 
caustic  soda  corresponds  to  4  grm.  of  soda,  to  y6$ 
grm.  of  hydrochloric  acid,  4*9  grm.  of  sulphuric  acid, 
and  63  grm.  of  oxalic  acid.  Each  cubic  centimetre 
of  deci-normal  solutions  represents  one-thousandth 
part  of  these  amounts. 

The  method  for  ascertaining  the  total  acidity  of  the 
stomach  contents  is  based  upon  the  quantity  of  a  deci- 
normal  solution  of  an  alkali  required  to  be  added  to 
a  known  quantity  of  the  contents  before  the  reaction 
becomes  neutral  or  slightly  alkaline.  Many  indicators 
have  been  used ;  the  majority  of  them  are  vegetable 
bodies,  such  as  litmus  or  cochineal,  which  do  not 
change  their  colour  with  sufficient  distinctness  when 
the  neutral  point  is  reached  to  allow  of  very  accurate 
observations  to  be  made  by  their  aid.  An  aniline 
body,  phenol-phthalein,  is  of  greater  service.  It  forms 
a  slightly  yellow  solution  in  alcohol,  remains  almost 


TOTAL    ACIDITY  35 

colourless  if  added  in  small  quantity  to  an  acid  liquid, 
but  becomes  of  a  pink  colour  in  an  alkaline  one.  If, 
therefore,  a  solution  of  deci-normal  sodium  hydrate 
be  dropped  into  lo  or  lOO  c.  c.  of  the  stomach  con- 
tents, to  which  a  drop  or  two  of  an  alcoholic  solution 
of  phenol-phthalein  has  been  added,  until  a  pink 
colour  appears  and  remains  permanent,  the  quantity 
of  soda  used  will  correspond  to  the  quantity  of  acid 
neutralised,  and,  therefore,  to  the  amount  of  acid  con- 
tained in  the  lo  or  too  c.  c.  of  the  stomach  contents. 
It  is  generally  recommended  that  the  soda  be  added 
until  a  pinkish  tinge  appears  and  does  not  vanish  on 
shaking.  Toepfer,  however,  says  that  more  accurate 
results  are  obtained  if  the  soda  be  added  until  the 
contents  become  of  a  dark  red  colour,  which  does  not 
increase  on  the  further  addition  of  the  alkali.  The 
depth  of  the  colour  reaction  in  such  a  case  should  be 
controlled  by  adding  an  excess  of  alkali  to  a  similar 
amount  of  the  contents  in  another  beaker,  and  by  com- 
paring the  colour  of  the  two  {v.  p.  68.) 

If  the  gastric  contents  are  so  highly  coloured  that 
all  reactions  with  colour  indicators  are  rendered 
obscure,  some  animal  charcoal  may  be  added  to  a 
known  amount  of  the  fluid,  the  mixture  well  shaken, 
filtered,  and  the  filtrate  tested  in  the  usual  way. 
Before  using  the  charcoal,  however,  it  is  well  to  ascer- 
tain whether  it  is  absolutely  neutral,  or  whether  it  con- 
tains any  matters  soluble  in  water.  To  do  this,  some 
may  be  agitated  with  distilled  water,  filtered,  and  the 
reaction  of  the  filtrate  tested  ;  while  another  portion 
of  the  filtrate  may  be  evaporated  to  dryness.  In  the 
first  case,  there  should  be  no  acid  or  alkali  present;  in 
the  second, no  solid  residue  remaining  after  evaporation. 


36  TOTAL    ACIDITY 

The  apparatus  required  for  the  estimation  of  the 
total  acidity  comprises  a  Mohr's  burette,  either  simple 
or  with  a  Shellbach's  band.  (The  presence  of  this 
band  is  of  advantage,  as  it  obviates  any  difficulty,  such 
as  may  be  caused  by  the  meniscus,  in  reading  the 
figure  on  the  burette  corresponding  to  the  level  of 
the  fluid.)  The  burette  should  be  graduated  to  fifths 
of  a  cubic  centimetre,  and  should  be  furnished  with 
a  stop-cock,  or  with  a  short  india-rubber  tube  con- 
trolled by  a  clamp ;  a  burette  stand,  preferably 
double,  and  two  or  three  porcelain  evaporating-basins  to 
hold  50  c.  c.  and  one  to  hold  100  c.  c.  are  also  necessary. 
White  porcelain  basins  are  preferable  to  glass  beakers, 
as  the  pink  colour  of  the  end  reaction  shows  up  more 
clearly  against  the  white  ground  than  against  the 
colourless  glass.  If  beakers  are  preferred,  a  similar 
number  of  the  same  capacity  should  be  provided,  and 
when  used,  should  be  placed  upon  a  sheet  of  white 
paper.  In  addition,  an  iron  tripod  covered  with 
copper  gauze  and  a  spirit  lamp,  or,  if  possible,  a 
Bunsen  gas  burner,  are  requisite. 

When  the  ordinary  burette  is  not  in  daily  use,  the 
soda  solution  is  apt  to  leak  out  at  the  stop-cock,  and 
to  dry,  in  the  form  of  carbonate  of  sodium,  on  that 
part  of  the  burette,  or  at  the  extreme  lower  end.  In 
such  cases  Kleinert's  burette  will  be  found  to  be  very 
convenient.  In  this  form  of  burette  the  stop-cock  is 
at  the  upper  end,  while  the  lower  end  is  more  drawn 
out.  To  fill  the  burette  the  stop-cock  is  opened,  the 
solution  sucked  up  as  far  as  necessary,  and  then  the 
stop-cock  is  closed.  The  pressure  of  the  air  keeps 
the  fluid  in  the  burette,  and  the  solution  can  be  run 
out  as  usual  by  turning  the  stop-cock  at  the  upper 


TOTAL    ACIDITY  3^ 

end.  After  titration  a  well-greased  glass  plate  is 
placed  in  contact  with  the  lower  opening,  and  sup- 
ported in  that  position. 

Practical  Examples  of  the  Estimation  of  Total 
Acidity. 

Reagents  reqidred. — A  deci-normal  solution  of  caustic  soda, 
of  which  I  c.  c.  contains  '004  grm.  of  sodium  h3'drate;  an 
alcoholic  solution  of  phenol-phthalein — either  two  or  four  per 
cent. ;  a  known  quantity  of  the  stomach  contents  which  it 
is  desired  to  test.  100,  or  10,  or  5  c.  c.  may  be  used.  10  c.  c. 
will  usually  be  found  to  be  the  most  convenient  quantity.  The 
contents  may  be  filtered  or  unfiltered. 

As  an  example,  the  estimation  of  the  total  acidity  of  a  speci- 
men of  stomach  contents  removed  three  hours  after  a  meal, 
which  consisted  largely  of  proteids,  will  be  instructive.  10  c.  c. 
were  tested  before  and  after  filtration.  To  each  a  few  drops  of 
phenol-phthalein  were  added,  and  the  deci-normal  solution  of 
soda  carefully  dropped  in.  In  the  unfiltered  specimen,  9*4  c.  c. 
of  the  soda  were  added  before  the  solution  became  permanently 
pink  in  colour,  and  io'6  c.  c.  in  the  case  of  the  filtered  specimen. 
That  is  to  say,  the  total  acidity  in  the  unfiltered  was  equal  to 
0'34  percent,  of  hydrochloric  acid,  and  in  the  unfiltered  contents 
to  0-38  per  cent. 

Unfiltered — (9'4x  '00365)  x  10  =  0-343 1 
Filtered — (io-6  x  •00365)  x  io  =  o'3869 

The  results  may  be  expressed  in  terms  of  hydrochloric  acid 
per  cent,  as  above,  or  in  the  same  terms  of  oxalic  acid  ;  or  may 
be  given,  as  Ewald  has  suggested,  simply  by  the  number  of  c.  c. 
of  the  deci-normal  solution  of  caustic  soda  required  to  neut?ralise 
100  c.c.  of  the  stomach  contents.  If  expressed  in  Ewald's 
notation,  the  acidity  of  the  unfiltered  specimen  would  be  repre- 
sented by  94,  of  the  filtered  by  106.  The  acidity  per  cent,  is 
calculated  from  the  number  of  the  c.  c.  of  the  soda  solution 
used  by  multiplying  it  by  the  quantity  of  acid  represented  in 
each  c.  c.  If  to  c.  c.  of  the  contents  be  originally  used,  the  figure 
obtained  represents  the  amount  of  acid  in  that  quantity,  and 
multiplying  by  10  gives  the  percentage  acidity. 


38  TOTAL   ACIDITY 

The  total  acidity  simply  expresses  the  acidity  value  of  the 
contents,  and  does  not  indicate  in  any  wa}'  the  component  parts 
to  which  it  is  due. 

Example  II. 

9  A.M.  Breakfast,  consisting  of  Benger's  Food  only. 

II. 15  A.M.  Contents  withdrawn.  10  c.  c.  tested  unfiltered. 
4*8  c.  c.  of  the  deci-normal  soda  solution  used. 

(4-8  X  -00365)  X  10  =  '1752  per  cent,  as  HCl  per  cent. 

Total  acidity  of  specimen  =  "1752  per  cent,  as  HCI  per  cent. 

Recorded  by  Ewald's  notation  =  48. 


Example  HI. 

From  the  same  case  as  II.,  after  treatment. 

9  A.M.  Breakfast — boiled  fish,  milk  and  water. 

II  A.M.  Contents  withdrawn.     10  c. c.  tested  unfiltered. 

N 
9*3  c.  c.  —  NaHO  used. 
^  10 

(9-3  X  -00365)  X  10  =  -33945- 

Total  acidity  of  specimen  =  -339  per  cent,  as  HCl. 

Ewald's  notation  =  93. 

If  it  is  wished  to  record  the  acidity  in  terms  of  oxalic  acid,  the 
calculation  in  Example  III.  would  be  as  follows  : — 

(9-3  X  -0063)  X  10  =  -5859  per  cent,  as  oxalic  acid. 
Similarly  in  terms  of  sulphuric  acid  : — 

(9*3  X  "0049)  X  10  =  '4557  per  cent,  as  H2SO4. 

2.    Estimation   of  Free   Acidity. 

It  is  often  of  great  importance  to  ascertain  whether 
part  of  the  total  acidity  is  formed  of  free  acids,  volatile 
or  non-volatile,  mineral  or  organic.  Numerous  tests 
have  been  suggested  for  the  qualitative  detection  of 
these  free  acids,  and  for  their  quantitative  estimation. 

Qualitative  Tests  for  the  Presence  of  Free  Acids. 

I.  Free  Acid  of  any  kind. — Three  reagents  are 
used  to  show  the  presence  or  absence  of  free  acid  of 


FREE    ACIDITY  39 

any  kind.  The  first,  Congo  red,  is  a  bright  red  powder, 
which  is  changed  to  an  equally  bright  blue  in  the 
presence  of  free  acids,  especially  of  free  mineral  acids, 
even  in  a  dilution  of  O'O02  per  cent.  As,  however, 
it  is  affected  to  some  extent  by  free  organic  acids,  it 
cannot  be  used  satisfactorily  for  the  accurate  deter- 
mination of  the  amount  of  free  mineral  acid  present. 
The  blue  coloration  caused  by  the  presence  of  free 
hydrochloric  acid  differs  slightly  from  that  brought 
about  by  free  organic  acids,  the  latter  causing  a 
slightly  more  violet  tinge.  Acid  salts  do  not  affect 
it.  The  most  convenient  way  to  use  Congo  red  is 
by  means  of  Congo  red  papers,  which  are  strips 
of  filter  paper  dipped  in  a  saturated  watery  solution 
of  the  dye  and  then  dried.  Tropceolin,  OO,  is  an  orange 
aniline  dye  (the  r orange  Poirier  of  the  French),  which 
is  only  slightly  soluble  in  water,  but  more  soluble  in  a 
mixture  of  alcohol  and  water.  Free  mineral  acids,  as 
dilute  as  0"025  per  cent.,  give  its  solution  a  bright  red- 
brown  tinge,  while  organic  acids  turn  it  slightly  red. 
Acid  salts  give  it  a  straw  yellow.  If  used  by  the  simple 
addition  of  the  stomach  contents  to  its  solution,  no 
reliance  can  be  placed  upon  its  reaction  as  a  means  of 
detecting  the  presence  of  free  hydrochloric  acid.  If, 
however,  a  small  quantity  of  the  tropaeolin  solution  be 
evaporated  at  or  below  the  body  temperature,  and, 
when  dry,  a  drop  of  the  stomach  contents  be  added, 
should  free  hydrochloric  acid  be  present  a  violet  or 
purple  tint  will  develop.  It  is  said  that  free  organic 
acids  do  not  give  this  last  reaction. 

Benzo-pitrpurin,  6  /3. — This  aniline  dye  has  been 
suggested  by  van  Jaksch  for  the  detection  of  free 
acids.     Test   papers  made  in  the  ordinary  way  may 


40  FREE    ACIDITY 

be  used.  If  free  hydrochloric  acid  be  present, 
the  purple  colour  of  the  dye  is  turned  dark  blue  and 
is  not  removed  by  ether.  With  organic  acids  the 
colour  becomes  much  darker, — in  fact,  a  brownish 
black,  but  it  is  removable  by  means  of  ether.  A  mix- 
ture of  the  mineral  and  organic  acids  gives  a  dark 
brown  tint,  only  partly  decolorised  by  ether. 

Leds  MetJiod. — Leo's  method  is  performed  in  the 
following  way  : — A  strip  of  blue  litmus  paper  is 
dipped  into  the  gastric  contents  and  kept  as  a  stand- 
ard. Some  of  the  contents  are  then  put  into  the 
watch-glass,  and  a  small  quantity  of  absolutely  pure 
calcium  carbonate  added.  After  stirring  the  solution 
with  a  glass  rod,  the  reaction  is  tested  with  blue  litmus 
paper  and  compared  with  the  standard.  If  the  litmus 
paper  is  no  longer  reddened  the  acidity  is  entirely  due 
to  free  acids  and  not  to  acid  salts.  If  the  red  colour 
is  not  so  pronounced,  both  free  and  acid  salts  are 
present.  If  there  is  no  change,  free  acids  are  absent, 
and  the  acidity  is  due  to  acid  salts  alone.  If  this 
procedure  be  undertaken  after  removal  of  the  organic 
acids  with  ether,  any  free  acid  shown  to  be  present 
must  be  hydrochloric  acid.  This,  however,  is  by 
no  means  a  trustworthy  method,  nor  is  it  quanti- 
tative. 

Methyl  violet  was  long  recommended  as  a  trust- 
worthy test,  but  it  has  been  often  shown  that  the  re- 
action, which  was  looked  upon  as  sure  evidence  of  the 
presence  of  free  hydrochloric  acid,  occurs  with  organic 
acids  also.  The  addition  of  0"024  per  cent,  of  hydro- 
chloric acid  to  a  dilute  solution  of  this  dye  changes 
the  red-violet  tint  to  a  sky-blue. 

The  colouring^  matter   of  Boj'deaux    Wine  and  of 


FREE    HYDROCHLORIC    ACID  41 

Bilberries  has  been  similarly  recommended  by  Uffel- 
mann  for  free  hydrochloric  acid,  but  it  is  subject  to 
the  same  fallacy  as  the  last  reagent. 

Emerald,  smaragd,  or  malachite  green,  probably  the 
vert  brilliant  of  Lepine,  changes  .from  dark  green  to 
light  green  in  the  presence  of  free  hydrochloric  acid. 
It  is  not  a  very  delicate  reagent.  The  same  may  be 
said  of  fuchsin. 

2.  Free  Hydrochloric  Acid  alone.  —  A. 
second  class  of  reagents  are  used  for  the  detection  of 
free  hydrochloric  acid. 

Giinzburg' s  Vanillin- Phloroghicin  Test. — This  test  is 
one  of  the  most  accurate  and  delicate  of  those  used 
at  the  present  time  for  the  detection  of  free  mineral 
acid.     It  is  made  up  as  follows  : — 

Phloroglucin,         .     2  grm.  xxx  grs. 

Vanillin,        .         .     i  grm.  xv  grs. 

Alcohol,         .         .  30  c.  c.  I  fl.  5. 

The  solution  has  a  slight  yellowish  colour.  If 
a  few  drops  of  this  reagent  and  an  equal  quantity  of 
the  stomach  contents  be  evaporated  to  dryness  in  a 
capsule  over  a  water-bath,  or  by  cautious  heating  with 
a  spirit-lamp,  care  being  taken  to  avoid  burning  the 
contents,  the  presence  of  free  mineral  acid  is  shown  by 
the  development  of  a  bright  rose-red  colour,  caused 
by  the  formation  of  minute  red  crystals. 

Organic  acids,  even  in  strong  solution,  do  not  give 
this  reaction  except  in  the  case  of  tartaric  acid,  while 
hydrochloric  acid  combined  with  proteids  causes  no 
red  coloration.  The  solution  is  capable  of  revealing 
the  presence  of  free  hydrochloric  acid  in  a  single  drop 
of  the  stomach  contents,  even  when  as  little  as  0"0i  per 


42  FREE    HYDROCHLORIC    ACID 

cent,  is  present.  It  is  quite  sufficient  to  obtain  a  faint 
streak  of  red  at  the  edge  of  the  drying  solution  to  be 
sure  that  free  hydrochloric  acid  is  present. 

The  Resorcin  Test. — The  solution  used  for  this 
test  contains  5  grm.  of  resorcin  and  3  grm.  of  cane 
sugar  in  100  c.  c.  of  weak  alcohol  ;  recommended  by 
Boas,  it  reacts  in  a  similar  way  to  Gunzburg's,  and  has 
the  advantage  of  being  much  cheaper,  but  is  not  quite 
so  delicate.  The  colour  struck  by  it  is  not  so  scarlet 
as  in  Gunzburg's  test,  but  is  rather  more  of  a  pink  tint. 

Mohrs  S2ilpho-cyanide  of  Potassmin  Test.  —  For 
this  test  2  c.  c.  of  a  10  per  cent,  solution  of  sulpho- 
cyanide  of  potassium  are  added  to  0'5  c.  c.  of  a  neutral 
solution  of  ferric  acetate,  which  should  be  of  a  strength 
of  from  4  to  5  per  cent.  ;  water  is  then  added  up  to 
20  c.  c.  If  a  solution  containing  free  hydrochloric 
acid  be  brought  in  contact  with  Mohr's  reagent,  a 
peach-red  colour  appears  at  the  point  of  junction  of 
the  two  liquids,  which  soon  becomes  brown  if  the 
free  hydrochloric  acid  present  be  concentrated.  The 
response  to  this  test  is  not  so  delicate  as  to  either 
Gunzburg's  or  Boas'  reagents. 

3.  For  Free  Organic  Acids. — The  three  reagents 
just  mentioned  are  used  to  indicate  the  presence  of 
free  hydrochloric  acid.  To  detect  the  organic  acids 
which  may  be  present  in  a  free  state : — 

(i.)  Uffelnianns  Reagent  may  be  made  use  of 
The  test  solution,  as  recommended  by  him,  is  com- 
posed of — 

Carbolic  acid  solution  (i  in  20),     .     10  c.  c.     3'jss. 
Distilled  ^Yater,       .         .  .     20  c.  c.     1,\\ 

Liquoris  ferri  perchloridi,       .  .       i  or  2  drops. 


ORGANIC    ACIDS  43 

On  addition  of  the  iron  solution  to  the  carbolic 
acid,  a  clear  violet,  or,  as  it  has  been  termed,  amethyst- 
blue  colour  is  produced.  The  mixture  should  be 
diluted  with  water,  if  it  is  so  dark  that  one  cannot  see 
through  it  when  some  of  it  is  poured  into  a  test-tube. 
A  good  rule  is  to  dilute  the  mixture  until  it  is  about 
the  colour  of  claret. 

The  proportions  given  above  are  not  essential.  In 
practice  it  is  quite  sufficient  to  add  a  drop  or  two  of 
the  perchloride  of  iron  solution  to  a  solution  of 
carbolic  acid  of  any  strength,  and  to  dilute  the 
mixture  with  distilled  water  until  the  colour  is  as 
deep  as  that  of  claret.  If  the  solution  be  kept 
made  up  for  any  length  of  time,  it  will  soon  be 
found  to  lose  its  characteristic  colour  and  to  react 
abnormally. 

If  a  solution  containing  lactic  acid  be  added  to  some 
of  this  reagent,  the  violet  colour  is  changed  to  a 
canary-yellow  when  the  acid  is  present  in  moderate 
quantity,  or  into  a  greenish-yellow  if  the  amount  be 
small.  As  little  as  0"0i  per  cent,  of  lactic  acid  will 
serve  to  produce  the  reaction.  Unfortunately  lactic 
acid  is  seldom  present  alone  in  the  stomach,  and  as 
other  acids  change  the  colour  of  the  fluid  in  a  different 
way,  the  result  of  the  reaction  may  be  very  indefinite. 
Thus,  free  hydrochloric  acid  simply  discharges  the' 
colour  of  the  solution  ;  when  combined  with  proteid 
bodies  it  gives  it  a  yellow-brown  tint,  which  is  very 
similar  to  that  produced  by  acetic  acid.  Butyric  acid 
discharges  the  colour  from  the  solution,  but  generally 
gives  it  a  greyish  opalescent  look.  Both  tartaric  and 
citric  acid  give  the  same  reaction  as  lactic.  Free 
hydrochloric    acid,    therefore,    simply    discharges    the 


44  ORGANIC    ACIDS 

colour,  lactic  acid  causes  it  to  become  a  bright  canary 
yellow,  acetic  and  combined  hydrochloric  acid  give  a 
yellowish  brown,  and  butyric  acid  a  greyish  opalescent 
appearance  to  the  solution. 

(2.)  Another  reaction  which  may  be  used  to  identify 
lactic  acid,  and  which  is  rather  more  delicate  than 
Uffelmann's,  is  brought  about  by  adding  one  or  two 
drops  of  a  dilute  solution  of  perchloride  of  iron  to  50  c.  c. 
of  distilled  water.  When  lactic  acid  is  added  to  this, 
even  in  very  dilute  proportions,  the  solution,  which  is 
almost  colourless,  develops  a  light  yellow  tint.  The 
three  acids  mentioned  above  do  not  give  this  reaction. 
A  few  drops  of  the  stomach  contents  dropped  into  the 
iron  solution  cause  the  same  change  of  colour,  should 
lactic  acid  be  present. 

In  the  two  last  tests  the  presence  of  alcohol,  sugar, 
or  phosphates  may  cause  a  similar  yellow  colour  to 
that  produced  by  lactic  acid. 

(3.)  Boas  has  introduced  a  more  complicated  test  for 
the  presence  of  lactic  acid,  in  which  a  certain  quantity 
of  the  stomach  contents  is  shaken  up  with  a  large 
excess  of  sulphuric  ether.  The  ether  used  should  be 
five  times  the  amount  of  the  stomach  contents.  The 
ether  extract  is  decanted  off,  and  contains  the  most 
of  the  lactic  acid  dissolved  in  it ;  after  evaporat- 
ing the  ether,  the  residue  is  dissolved  in  water,  and 
heated  in  a  porcelain  basin  with  sulphuric  acid  and 
peroxide  of  manganese.  Any  lactic  acid  which  may 
be  present  is  decomposed  into  formic  and  acetic 
aldehyde.  If  a  drop  of  a  solution  of  iodine  be  added 
to  this,  iodoform  forms,  and  can  be  easily  recognised 
by  its  peculiar  smell.  Such  an  ethereal  extract  will 
contain  both   butyric  and  acetic   acids  if  these  acids 


ORGANIC    ACIDS  45 

are  present  in  the  stomach  contents,  and  they  may  be 
identified  by  their  characteristic  odours  ;  or,  in  the 
case  of  acetic  acid,  if  after  neutraHsing  the  ether 
extract  with  carbonate  of  soda  a  few  drops  of  a 
neutral  solution  of  ferric  perchloride  be  added,  by  the 
bright  red  colour  produced. 

If  the  stomach  contents  have  a  pronounced  yellow 
colour,  which  would  obscure  the  reaction  obtained  with 
Uffelmann's  reagent,  or  if  the  three  organic  acids  are 
present  together,  an  easy  method  of  detecting  the 
presence  of  lactic  acid  is  to  evaporate  a  large  quantity 
of  the  stomach  contents,  say  50  or  100  c.  c,  down  to 
10  c.  c,  in  an  evaporating  basin  over  a  water-bath. 
Allow  the  residue  to  cool,  and  add  50  c.  c.  of  ether. 
As  acetic  and  butyric  acids  are  volatile,  they  are 
driven  off  during  concentration  on  the  bath  ;  the  ether 
dissolves  out  the  lactic  acid  and  leaves  the  hydro- 
chloric acid  in  the  residue.  The  ether  extract  is  then 
evaporated  to.  dryness  as  before,  and  the  same  tests 
applied. 

(4.)  To  ascertain  more  particularly  the  presence  of 
the  two  volatile  organic  acids  the  filtered  stomach 
contents  are  distilled.  Three-fourths  of  the  liquid 
should  be  driven  off,  and,  as  lactic  acid  is  not  volatile, 
and  as  free  hydrochloric  acid  only  volatilises  when 
there  is  little  or  no  water  left,  the  two  volatile  organic 
acids  are  obtained  in  a  pure  state  in  the  receiver. 
Butyric  acid  can  be  recognised  by  its  peculiar  smell, 
like  that  of  rancid  butter,  or,  by  heating  it  with  a 
small  quantity  of  alcohol  and  a  drop  or  two  of 
strong  sulphuric  acid,  by  the  formation  of  butyric 
ether,  which  gives  off  an  odour  resembling  that  of 
pine-apple    rum.      Similarly,    acetic    ether    may   be 


■46  ORGANIC    ACIDS 

formed  from  acetic  acid,  affording  a  peculiar  but 
agreeable  odour.  Or  it  can  be  recognised  by  the 
reaction  which  follows  the  addition  of  a  few  drops 
of  the  perchloride  of  iron.  Acetates  also  can  be 
identified  in  the  contents  by  means  of  the  cacodyl 
reaction  ;  that  is,  if  caustic  potash  and  a  little  arseni- 
ous  acid  be  added  to  the  solution  and  the  mixture 
evaporated,  a  nauseous,  penetrating  odour  develops. 
The  amounts  present  of  the  two  volatile  organic  acids 
may  be  calculated  by  titration  of  the  distillate  in  the 
usual  way,  and  knowing  the  total  acidity  of  the  stomach 
contents  beforehand,  subtraction  of  the  figure  thus 
obtained  will  give  the  acidity  due  to  lactic  and  hydro- 
chloric acid  in  the  remainder. 

Strauss*  suggests  that  the  test  for  lactic  acid  with 
dilute  perchloride  of  iron  should  be  performed  as 
follows  : — Exactly  the  same  amount  of  the  gastric  con- 
tents should  be  taken,  and  the  same  amount  of  ether 
used  on  each  occasion.  The  residue  left  on  evaporat- 
ing the  ether  is  diluted  with  water  to  the  same  degree 
at  each  examination,  and  two  drops  of  a  solution  of 
one  part  of  liquor  ferri  perchloridi  to  nine  of  water 
added.  The  test  performed  in  this  way  is  very 
delicate,  and  the  depth  of  tint  developed  may  serve 
as  an  indication  of  the  quantity  of  acid  originally 
present. 

*  Berliner  klin.  Wochenschrift^  1895,  No.  37. 


CHAPTER  V. 

THE  EXAMINATION  OF  THE  FLUID  REMOVED 
FROM  THE  STOMACH,  OR  OF  THE  VOMIT— 
(Continued). 

3.    The   Quantitative    Estimation   of   the   different 
Factors  which  go  to  make  up  the  Total  Acidity. 

For  Free  Hydrochloric  Acid  only — Mintz's  Method — Hydrochloric  Acid, 
free  and  combined  with  Proteids — Sjoqvist's  Method — For  all  the 
Acids  Present — Cahn  and  von  Mering — Mintz-Boas — Hayem  and 
Winter — Toepfer — Martins  and  Liittke — The  Author's  Modifica- 
tion of  Hayem  and  Winter's  Method — For  the  Organic  Acids — 
Methods  used  less  frequently — Contejean — Hoffmann — Braun — 
Mierzynski — Table  of  Methods. 

In  the  preceding  chapters  the  methods  described 
apply  only  to  the  individual  conditions  under  which 
the  different  acids  are  found.  To  obtain  the  greatest 
amount  of  information  concerning  the  chemistry  of 
the  stomach  contents,  we  must  make  use  of  methods 
which  will  indicate  both  the  acids  present  and  the 
chemical  forms  in  which  they  exist.  Unfortunately, 
owing  to  the  complexity  of  the  subject,  most  of 
these  methods  are  so  complicated,  and,  as  a  rule,  so 
difficult,  that  they  are  out  of  the  reach  of  any  one 
unskilled  in  chemical  analysis,  or  unprovided  with  the 
somewhat  large  amount  of  apparatus  necessary.  As 
the  practitioner,  as  a  rule,  has  little  time  on  his  hands, 
and   as   most  of  the   methods  involve  lengthy  pro- 


48  QUANTITATIVE    ESTIMATION    OF   ACIDS 

cesses,  if  they  are  to  be  conscientiously  and  accurately 
performed,  the  majority  of  them  are  impossible  in 
general  practice. 

The  different  acid  factors  which  require  quantitative 
investigation  are — i.  The  total  acidity;  2,  the  con- 
stituents of  that  acidity;  3,  the  presence  of  free  hydro- 
chloric acid ;  4,  the  portion  of  hydrochloric  acid 
combined  with  proteid  bodies ;  5,  the  presence  of 
volatile  and  non-volatile  organic  acids  ;  and,  6,  the 
acidity  due  to  acid  salts. 

The  estimation  of  the  total  acidity  and  the  con- 
sideration of  the  tests  for  the  individual  acids  have 
already  been  dealt  with. 

1.   The   Quantitative   Estimation   of    Free    Hydro- 
chloric  Acid. 

Mintz's  Method. — Mintz  has  recommended  the  use 
of  Giinzburg's  reagent  {cf.  p.  41)  for  the  quantitative 
estimation  of  free  hydrochloric  acid. 

A  deci-normal  solution  of  caustic  soda  is  added 
from  a  burette  to  10  c.  c.  of  the  stomach  contents, 
either  filtered  or  unfiltered,  until  the  red  coloration 
disappears  which  forms  on  evaporating  a  drop  of  the 
solution  with  vanillin-phloroglucin. 

The  quantity  of  soda  added  is  regarded  as  equiva- 
lent to  the  amount  of  free  hydrochloric  acid  present. 
Mintz  has  demonstrated  that  when  hydrochloric  acid 
is.  present  both  in  a  free  state  and  combined  with 
proteids,  the  alkali  combines  first  with  the  free  acid. 
The  exact  point  at  which  the  red  coloration  with 
Giinzburg's  reagent  disappears  is  noted,  and  the 
amount  of  the  soda  solution  used  represents  the 
quantity   of  free   hydrochloric   acid   in-  the  solution. 


FREE    HYDROCHLORIC    ACID  ;    MIXTZ  49 

Example : — 

I.  Tested  by  Evaporation  Method  (cf.  p.  74). 

Stomach  contents  removed  four  hours  after  food — meat  and 
jelly,  with  a  tumbler  of  milk.     Contents  yellowish  white^  full  of 
small  debris^  slight  gastric  odour. 
Total  acidity  (tested  unfiltered,  with 

deci-normal     soda     and      phenol- 

phthalein),     .....     0'3723  per  cent,  or  102. 
Acidity  combined  with  proteids  and 

in  acid  salts  (after  evaporation  at 

100°  C), 03358  per  cent.,  or  92. 

Leaving  as  free  acidity      .         .         .     0'0365  per  cent.,  or  10. 

The  free  acid  present  consisted  entirely  of  hj'drochloric  acid  ; 
no  organic  acids  were  present. 

2.   The  Same  Tested  with  the  Vaxillix-Phloroglucix 
Reagent. 

Deci-normal  solution  of  soda  was  added  to  10  c.  c.  of  the  con- 
tents, and  after  every  two  drops  the  fluid  was  tested  with 
Giinzburg's  reagent.  A  negative  reaction  occurred  when  i  c.  c. 
had  been  added.  The  free  hydrochloric  acid,  therefore,  was 
•0365  per  cent.,  corresponding  exactly  to  the  figure  obtained 
by  the  evaporation  method. 

In  performing  this  test  I  have  found  it  ver}-  con- 
venient to  dry  several  c.  c.  of  Giinzburg's  solution  on 
the  surface  of  a  flat-bottomed  evaporating  basin,  and, 
after  the  addition  of  every  two  or  three  drops  of  the 
soda,  to  place  a  drop  of  the  contents  in  sequence  on 
the  surface  of  the  basin  by  means  of  a  glass  rod. 
The  basin  is  then  warmed  over  a  flame  or  kept  on  a 
water  bath.  After  the  addition  of  each  drop  or  two 
drops  of  the  soda  to  the  mixture  the  amount  run  from 
the  burette  is  noted,  and  a  drop  of  the  mixture  placed 
in  regular  order  on  the  dried  reagent  in  the  basin. 

D 


50  QUANTITATIVE    ESTIINIATION    OF    ACIDS 

The  exact  point  at  which  the  free  hydrochloric  acid 
has  been  completely  neutralised  can  then  be  easily 
determined,  and  by  reference  to  the  amount  of  soda 
used  corresponding  to  the  first  absence  of  the  red 
reaction  in  the  basin,  the  equivalent  amount  of  free 
acid  present  can  be  estimated. 

This  method  is  very  easy  and  does  not  take  up 
much  time.  It  appears  to  be  accurate  when  the 
contents  contain  only  hydrochloric  acid,  either  free 
or  combined  with  proteids.  The  presence  of  free 
organic  acid  vitiates  the  result.  Thus,  if  a  solution  is 
made  of  hydrochloric  acid  and  water,  and  the  amount 
of  free  hydrochloric  acid  present  estimated  by  this 
method  in  one  portion,  and  then  if  a  small  quantity  of 
acetic  or  lactic  acid  is  added  to  a  similar  quantity  of 
the  same  solution,  the  amount  of  free  hydrochloric  acid 
registered  exceeds  that  known  to  be  present  in  the 
original  watery  solution.  Some  of  the  alkali  added 
combines  with  the  organic  acids,  although,  as  it  has 
a  greater  affinity  for  free  hydrochloric  acid,  the 
amount  is  not  great. 

The  soda  does  not  appear  to  act  on  the  hydro- 
chloric acid  combined  Avith  proteids  until  all  the  free 
acid  has  been  neutralised. 

This  process  can  be  reversed  in  cases  in  which  there 
is  no  free  hydrochloric  acid  present,  and  used  for  the 
estimation  of  the  amount  of  hydrochloric  acid  which 
it  is  necessary  to  add  before  the  affinities  of  all  the 
proteids,  still  incompletely  combined  with  the  acid, 
and  of  the  organic  salts  present,  are  fully  satisfied. 
For  this  purpose  a  deci-normal  solution  of  hydro- 
chloric acid  is  run  into  lo  c.  c.  of  the  contents,  drop 
by  drop,  until  the  reaction  with  vanillin-phloroglucin 


FREE    HYDROCHLORIC    ACID  ;    MINTZ  5 1 

is  positive.  The  amount  of  the  deci-normal  solution 
added  represents  the  quantity  necessary  to  satisfy  the 
requirements  of  the  proteids  and  organic  salts  of  the 
fluid,  so  as  to  allow  of  the  presence  of  a  trace  of  free 
hydrochloric  acid.  As  the  combination  of  the  acid 
with  proteids  is  not  an  instantaneous  process,  it  is  as 
well  to  allow  the  solution  to  stand  for  half  an  hour  or 
so,  after  the  first  positive  result  has  been  obtained, 
and  then  again  to  test  it.  Usually  a  further  small 
addition  of  the  acid  will  be  found  to  be  required. 


Example. 

Gastric  Contents ;  un filtered  ;  removed  two  hours  after  a  light 
breakfast — little  odour;  watery;  digestion  weak  ;  no  fermenta- 
tion. 

N 
-    Total  aciditv — 10  c.  c.  =  4  c.  c.  NaHO  —   =  o'i46  per  cent. 

10  ' 

(or  40). 

Free  hydrochloric  acid  absent. 


10  c.  c.  taken,  and  deci-normal  hydrochloric  acid  added. 

Giinzburg's  reagent  gave  a  positive  reaction  after  i"5  c.  c. 
were  added,  or  0-05475  per  cent.  (15).  That  is  to  say,  that 
before  free  hydrochloric  acid  could  appear  in  this  sample  of 
stomach  contents,  0*0547  per  cent,  of  hydrochloric  acid  re- 
quired to  be  added  to  it,  making  a  total  acidity  of  0-2007  per 
cent.  The  positive  reaction  first  appeared  after  1-3  c.  c,  but  on 
allowing  the  solution  to  stand  for  fifteen  minutes,  it  could  not 
be  obtained  until  o'2  c.  c.  additional  was  run  in. 

2.  The  Estimation  of  Hydrochloric  Acid,  free 
and  combined  -with  Proteids. 

The  Method  of  Sj'dqvist. — Sjoqvist's  *  method  con- 

*  Zeitschrift  fiir  Phys.  Chemie,  vol.  xiv.,  p.  I. 


52  ESTIMATION    OF    HYDROCHLORIC    ACID 

sists  in  evaporating  a  certain  quantity  of  the  stomach 
contents  to  dryness  after  the  addition  of  barium 
carbonate,  care  being  taken  not  to  add  an  excess  of  this 
salt.  It  is  then  incinerated.  In  the  ash  the  chlorine 
is  present  as  chloride  of  barium,  while  any  organic 
barium  salts,  which  may  have  been  formed,  are  con- 
verted by  incineration  into  carbonate  of  barium.  As 
carbonate  of  barium  is  insoluble  in  hot  water,  while 
chloride  of  barium,  on  the  other  hand,  is  soluble  in  it, 
the  two  salts  can  be  separated  from  one  another  by 
washing  the  ash  with  hot  water.  Thus  lo  c.  c.  of  the 
stomach  contents,  filtered  or  unfiltered,  are  mixed 
with  about  0*05  grm.  of  carbonate  of  barium  in  a 
platinum,  or  nickel,  capsule,  evaporated  to  dryness, 
and  then  reduced  to  ash.  After  cooling,  the  soluble 
salts  are  dissolved  in  50  to  75  c.  c.  of  boiling  water,, 
the  insoluble  remainder  being  separated  by  filtration. 
The  solution  which  has  passed  through  the  filter 
paper  contains  all  the  barium  chloride  formed  from 
the  hydrochloric  acid  in  the  10  c.  c.  of  the  stomach 
contents.  As  first  described  by  Sjoqvist,  the  barium 
chloride  is  converted  into  the  carbonate  by  the  addition 
of  caustic  soda,  and  as  the  carbonate  is  insoluble  in 
water  it  is  thrown  down  as  a  flocculent  precipitate.  The 
mixture  is  again  filtered.  The  precipitate  of  barium 
carbonate  on  the  filter  paper  is  collected  and  washed, 
dissolved  in  hydrochloric  acid,  and  evaporated  to 
dryness. 

A  modification  of  the  method  has  been  proposed 
by  van  Jaksch,*  in  which  the  chloride  of  barium  in 
the  first  filtrate  from  10  c.  c.  of  the  stomach  contents 
is  converted  into  sulphate  of  barium  by  the  addition 

* Motiatshefte  far  Chemie,  vol.  x.,  1889,  p.  21 1. 


METHOD    OF    SJOQVIST  53 

of  pure  sulphuric  acid ;  the  sulphate  is  then  caught 
on  an  ash-free  filter  paper,  dried,  ashed,  and  weighed. 
The  amount  of  sulphate  of  barium  obtained  multiplied 
by  0'3i32  gives  the  amount  of  HCl  present  in  lo  c.  c. 
of  the  contents.  In  the  original  method,  after  dissolv- 
ing the  barium  carbonate  in  hydrochloric  acid  and 
evaporating  it  to  dryness,  the  ultimate  residue  obtained 
is  again  dissolved  in  water  and  titrated  with  a  silver 
nitrate  solution.  As  the  residue  consists  solely  of 
chloride  of  barium,  the  quantity  of  standard  silver 
solution  used  before  the  end  reaction  with  chromate 
of  potash  is  reached,  corresponds  to  the  chlorine 
present,  i  c.  c.  of  the  silver  solution  represents  O'OOi 
grm.  chloride  of  sodium,  and  the  amount  of  hydro- 
chloric acid  present  may  be  calculated  by  multiplying 
the  number  of  cubic  centimetres  of  the  silver  solution 
used  by  36-5  (HCl)  and  dividing  by  58-5  (NaCl). 
The  figure  obtained  represents  the  quantity  of  hydro- 
chloric acid  in  10  c.  c.  of  the  stomach  contents. 
Sjoqvist  has,  however,  modified*  his  method  during 
the  last  year  or  so.  He  changes  the  barium  chloride 
extracted  from  the  ash  into  barium  chromate  by  add- 
ing ammonium  chromate.  The  barium  chromate 
thus  formed  is  insoluble  in  acetic  acid,  and  can  readily 
be  freed  from  the  am.monium  chloride  which  is 
formed.  The  chromic  acid  present  is  estimated  by 
the  addition  of  hydrochloric  acid  and  iodide  of  potas- 
sium. 

2  BaCr04    +  16  HCl  +  6  KI  =  2  BaCIs  +  Creels  +  8  HjO  + 
6  KCl  +  3  I2. 

These  reagents  form  chloride  of  barium,  chloride  of 

*  Skand.  Arch.f.  Phys.  v.,  4/6,  s.  277. 


54  ESTIMATION    OF    HYDROCHLORIC    ACID 

potassium,  chloride  of  chromium,  and  free  iodine  from 
the  chromate  of  barium.  The  free  iodine  is  titrated 
with  standard  hyposulphite  of  sodium  solution. 

Still  another  modification  of  the  process  has  been 
suggested  by  Salkowski,*  who  converts  the  sulphate 
of  barium  formed  in  van  Jaksch's  method  into  chloride 
of  barium  by  the  addition  of  hydrochloric  acid,  and 
titrates  this,  as  in  the  original  method,  with  nitrate 
of  silver  and  chromate  of  potash. 

This  method,  either  in  its  original  form  or  any  of 
its  modifications,  is  theoretically  a  very  perfect  one, 
but  requires  experience  and  facilities  which  are  seldom 
within  the  reach  of  the  ordinary  practitioner.  It  takes 
no  note,  moreover,  of  the  quantity  of  hydrochloric  acid 
combined  with  albuminous  bodies,  and  Martius  and 
Llittke  have  found  that,  when  free  hydrochloric  acid 
is  present  in  small  quantity  and  the  combined  acid  in 
a  greater  proportion,  the  results  obtained  by  the 
method  are  frequently  much  below  the  truth.  The 
results  simply  indicate  the  total  chlorine  present  in 
the  stomach  contents  in  the  form  of  hydrochloric 
acid,  free  or  combined  with  proteids.  No  indication 
is  given  of  the  amount  of  acidity  due  to  organic  acids 
or  acid  salts. 

During  the  process  of  incineration  of  the  residue 
after  evaporation  of  the  fluid  mixed  with  barium  car- 
bonate, some  of  the  barium  salt  may  be  reduced  to 
the  hydrate,  which  is  partly  soluble  in  hot  water. 

To  ascertain  its  presence  a  drop  of  phenol- phthalein 
is  added.  If  a  pink  colour  develops,  the  filtrate  is 
alkaline,  owing  to  the  presence  of  barium  hydrate. 
Air  should  be  blown  through  the  fluid  through  a  glass 

■      *  Virck.  Arch.,  Bd.  73,  s.  292. 


METHOD    OF    SJOQVIST  55 

tube,  or  a  stream  of  carbonic  acid  gas  passed  through 
it,  until  it  is  colourless  again.  It  is  then  refil- 
tered. 

Example  of  SJoqvisfs  Method,  as  modified  by  van 
Jaksch. 

Stomach  Contents,  Filtered  and  Unfiltered. 

Two  hours  after  a  light  meal  of  proteids  and  bread,  from  a 
case  of  Hyperchlorhydria. 

Contents  have  no  smell,  save  slightly  "gastric."  Unfiltered, 
are  full  of  small  brown-grey  debris  ;  filtered,  are  clear  and  almost 
colourless. 


Total  acidity — Unfiltered,  0'3942  per  cent.,  or  io8. 

Filtered,     o'365  per  cent.,  or  loo. 
Total  Chlorine — Unfiltered,  0-4469  per  cent. 
(AgNOa  and  KaCrOJ 
Filtered,  ovi.742  per  cent. 
No  organic  acids  were  present. 


Some  carbonate  of  barium,  previously  found  to  be  chlorine- 
free,  was  added  to  10  c.  c.  both  of  the  unfiltered  and  filtered 
contents  in  two  crucibles,  dried  over  a  water  bath,  and  inciner- 
ated over  a  naked  flame. 

After  cooling,  the  ash  was  washed  out  of  the  crucibles  with 
hot  distilled  water  on  to  filter  papers,  and  further  washed  until 
the  filtrate  reached  an  amount  of  about  100  c.  c.  Excess  of 
dilute  pure  sulphuric  acid  was  then  added  to  each  filtrate,  and 
the  resulting  precipitate  caught  on  ash-free  filter  papers,  washed 
with  distilled  water,  and  dried.  The  papers  were  then  inciner- 
ated in  porcelain  crucibles  of  known  weight,  and  the  weight  of 
the  ash  determined. 

Weight  of  Barium  Sulphate  in  lo  c  c.  Hydrochloric  acid 

per  cent. 

Unfiltered,     0-121  x  0-3132  =•  0-037S9  grm.  HCl.        0-3789 
Filtered,         0-130  x  0-3132  =  0-04071  grm.  HCl.        0-4071 


That  is  to  say,  of  the  total  chlorine  in  the  unfiltered  contents, 
0-4469  per  cent.,  Sjoqvist's  method  gives  0-3789  per  cent,  as  in 


56  ESTIMATION    OF    ALL    THE    ACIDS 

the  form  of  hydrochloric  acid^  leaving  o"o68  per  cent,  as 
inorganic  salt ;  and  in  the  filtered,  of  the  o"4742  per  cent,  total, 
0*407 r  per  cent,  consists  of  hydrochloric  acid,  and  o'o67i  per 
cent,  of  chlorine  in  an  inorganic  form. 

Estimation  of  the  inorganic  chlorine  after  simple  incineration 
at  a  dull  red  heat  gave  o'i368  per  cent,  for  the  unfiltered,  and 
o"i73  per  cent,  in  the  filtered  contents.  The  results  of  Sjoqvist's 
method  gave,  therefore,  what  appears  to  be  too  high  values  for 
the  hydrochloric  acid  present. 


3.  The  Estimation  of  all  the  Acids  present  in 
the  Stomach  Contents. 

{a.)  The  Method  of  Cahn  and  von  Mering. — This 
method  aims  at  the  exact  determination  of  the  total 
hydrochloric  acid,  the  volatile  acids,  and  the  lactic 
acid  of  the  stomach  contents.  Fifty  c.  c.  of  the  con- 
tents after  filtration  are  distilled  over  a  naked  flame 
until  three-fourths  of  the  liquid  have  gone  over.  The 
residue  in  the  retort  is  again  made  up  with  distilled 
water  to  50  c.  c,  and  re-distilled  until  three-fourths  have 
a  second  time  passed  over  into  the  receiver.  The  dis- 
tillate contains  all  the  volatile  organic  acids,  and,  if  it 
be  titrated  with  a  deci-normal  solution  of  soda,  their 
proportion  in  the  50  c.  c.  can  be  determined.  The 
residue  in  the  retort  or  flask  is  shaken  up  with 
500  c.  c.  of  pure  ether,  and  the  ether  decanted  off.  This 
procedure  is  repeated  six  times.  The  total  ether 
decanted  off  on  the  six  occasions  is  mixed  together, 
evaporated,  and  the  residue  titrated  with  soda  in  the 
usual  way.  The  figure  obtained  represents  the  quan- 
tity of  lactic  acid  originally  present  in  50  c.  c.  of  the 
filtered  stomach  contents.  To  the  concentrated  re- 
mainder in  the  retort  after  the  removal  of  the  ether,  a 
quantity  of  freshly  precipitated  cinchonin  is  added  to 


METHOD  OF  CAHN  AND  VON  MERING    57 

excess,  until  the  reaction  becomes  neutral.  The 
mixture  is  then  washed  into  a  separating  funnel  with 
chloroform,  and  shaken  four  or  five  times  with  fresh 
quantities  of  chloroform.  The  chloroform  solutions, 
separated  from  the  stomach  contents,  are  distilled, 
the  chloroform  driven  off,  and  the  residue  remaining 
is  dissolved  in  water  acidified  with  pure  nitric  acid. 
The  chlorine  present  in  it  is  then  precipitated  with  an 
excess  of  silver  nitrate.  The  chloride  of  silver  which 
forms  is  weighed  in  the  usual  way,  the  amount  of 
the  silver  salt  obtained  being  reduced  to  terms  of 
hydrochloric  acid  by  multiplying  its  weight  by 
0-25427. 

This  method  is  costly,  complex,  and  difficult, 
while  the  large  amounts  of  ether  used  to  take  up 
the  lactic  acid  remove  a  considerable  proportion  of 
the  hydrochloric  acid  present.  No  notice  is  taken  in 
the  method  of  the  hydrochloric  acid  combined  with 
proteids.  For  these  reasons  the  method  cannot  be 
recommended. 

{b.)  The  Mints-Boas'  Method. — Boas  has  modified 
the  method  as  recommended  by  Mintz  by  removing 
the  organic  acids  present  in  the  contents  with  ether, 
decanting  the  ether,  and  estimating  the  presence  of 
free  hydrochloric  acid  in  the  residue  by  adding  a 
deci-normal  soda  solution  until  Congo  red  paper  no 
longer  responds  to  its  action — that  is,  until  it  is  no 
longer  blued.  It  is  by  no  means  certain  that  ether 
removes  all  the  organic  acids  present,  while  Congo 
red  is  not  a  satisfactory  indicator.  The  usual  quantity 
of  ether  which  is  recommended  to  be  used  is  100  c.  c. 
to  10  c.  c.  of  the  stomach  contents.  As  much  more 
ether  is  necessary  to  extract   all  the  organic  acids, 


58  THE    METHOD    OF    MINTZ-BOAS 

the  process  is  rendered  very  expensive,  while  the 
large  quantity  of  ether  required  allows  some  of  the 
mineral  acid  to  be  removed  in  it. 


Exaviple  of  the  Mints-Boas'  Method. 

Contents  from  a  dilated  stornach.  Large  amount — 1950  c.  c. 
Sour  smell ;  fermenting  scum  on  surface  on  standing  ;  deposit 
of  grey-brown  debris  at  the  foot;  gas  bubbles  forming. 

Filtered.       Filtrate  slow  in  passing  through  paper,  greyish 

opalescent  in  colour. 

N 
Total  acidity,  10  c.  c,  io'6  c.  c.  —  soda  added  =  o"3869  per 

cent.,  or  106. 


10  c.  c.  shaken  up  with  100  c.  c.  of  ether,  placed  in  a  separating 
funnel,  and  the  lower  watery  layer  removed. 

To  this  deci-normal  soda  solution  was  added,  and  the  fluid 
tested  with  Congo  red  paper.  3  c.  c.  were  required  to  be  added 
before  the  paper  fiiiled  to  respond,  though  the  colour  shown 
by  it  was  violet-blue  throughout.  (Phloroglucin-vanillin  gave 
no  reaction  from  the  commencement.)  The  10  c.  c.  were  again 
shaken  up  with  100  c.  c.  of  fresh  ether,  the  ether  remov^ed,  and 
the  process  repeated  three  times  in  all. 

The  watery  remainder  still  changed  the  colour  of  Congo  red 
slightly — i.e.,  to  a  light  violet. 

The  acidity  of  this  remainder,  tested  with  phenol-phthalein, 

N 
was  equal  to  6-5  c.  c.  of —  soda  solution,  0*237  per  cent.,  or  65, 

giving  0-1499  psi"  cent,  removed  by  the  ether. 


From  other  analyses,  this  specimen  was  found  to  contain  no 
free  hydrochloric  acid,  0-2319  per  cent,  of  hydrochloric  acid 
combined  with  proteids,  0-0219  per  cent,  of  free  acid,  due  to 
acetic  acid,  and  o"i33i  per  cent,  of  lactic  acid.  The  sum, 
therefore,  of  the  organic  acids — 0*155  P^r  cent. — exceeded  the 
quantity  removed  by  the  300  c.  c.  of  ether  by  0-0051  per  cent. 


METHOD    OF    HAYEM    AND    WINTER  59. 

(c.)  The  Process  of  Hayem  and  Winter.  —  The 
method  of  Hayem  and  Winter*  is  based  upon  an 
altogether  different  foundation.  It  depends  chiefly  upon 
the  fact  that  a  solution  of  hydrochloric  acid  in  water, 
or  added  to  a  solution  of  carbohydrate  or  extractive 
bodies,  volatilises  completely  when  the  mixture  is 
dried  at  the  boiling  point.  On  the  other  hand,  if 
the  solution  to  which  the  hydrochloric  acid  has  been 
added  contains  any  proteid  bodies,  evaporation  to 
dryness  at  100°  C.  does  not  suffice  to  drive  off  all  the 
hydrochloric  acid,  as  that  part  of  it  which  has  entered 
into  loose  chemical  combination  with  the  proteid  re- 
mains behind.  They  also  state  that  the  only  factor 
capable  of  accurate  determination,  among  those  to 
which  the  acid  reaction  of  the  stomach  contents 
is  due,  is  the  chlorine.  If  the  total  acidity  be  known, 
and  the  exact  amount  ol'  chlorine  present  be  estimated 
both  as  hydrochloric  acid,  free  or  combined  with 
proteids,  and  as  inorganic  salt,  the  proportion  of  the 
chlorine  in  the  form  of  hydrochloric  acid  subtracted 
from  the  total  acidity  will  indicate  the  proportion  of 
acidity  unconnected  with  this  acid.  Thus,  they 
proceed  to  investigate  the  forms  in  which  the  chlorine 
in  the  stomach  contents  is  present  as  follows  : — 

Measure  out  5  c.  c.  of  the  filtered  contents  into 
three  crucibles,  which  we  may  term  A,  B,  and  C. 
To  A  an  excess  of  pure  carbonate  of  sodium  is  added, 
so  as  to  convert  all  the  chlorine  present  into  chloride 
of  sodium.  The  three  crucibles  are  then  dried  on  a 
water-bath  at  100°  C,  and  are  allowed  to  remain  there 
for  at  least  one  hour  after  their  contents  have  been 
rendered  thoroughly  dry.     (If  there  is  much  proteid 

*  Du  Chimisme  Stomacalf,  Paris,  189 1. 


6o  THE    METHOD    OF 

matter  in  the  contents  and  an  excess  of  free  hydro- 
chloric acid,  the  contents  of  capsule  B  should  be 
re-dissolved,  after  drying,  in  distilled  \A^ater,  again 
dried,  and  the  manoeuvre  repeated  as  long  as  a  drop 
of  the  contents,  after  adding  water,  causes  a  red 
coloration  when  tested  with  vanillin-phloroglucin.) 

The  dried  contents  of  capsule  B  are  then  dissolved 
in  a  small  quantity  of  distilled  water,  an  excess  of  the 
carbonate  of  soda  added,  and  the  mixture  again  dried. 
In  the  first  capsule,  capsule  A,  the  total  chlorine  is  in 
the  form  of  inorganic  salts  ;  in  capsule  B  Ave  have 
the  chlorine,  which  has  been  left  after  evaporation  to 
dryness  at  ioo°  C.  in  an  inorganic  form  ;  while  capsule 
C  contains  simply  the  dried  contents.  Each  of  the 
three  capsules  is  now  heated  over  a  naked  flame  until 
all  the  organic  matter  in  their  contents  has  been 
burned  off.  The  heat  employed  should  not  be  too 
great ;  a  dull  red  heat  is  all  that  is  required,  for 
chlorides  are  easily  driven  off  at  a  higher  temperature. 
After  incineration,  when  the  crucibles  have  cooled 
down,  a  slight  excess  of  pure  nitric  acid  is  added, 
along  AA^th  some  distilled  Avater.  The  crucibles  are 
then  heated  again  until  their  contents  reach  the  boil- 
ing point,  to  drive  off  carbonic  acid.  To  each  solu- 
tion carbonate  of  calcium  or  of  sodium  is  noAv  added 
up  to  the  neutral  point,  or  to  a  point  slightly  beyond  it. 
The  contents  of  the  crucibles  are  then  throAvn  on 
filter  papers  and  the  residue  Avashed  AAdth  boiling 
Avater.  The  filtrates  are  tested  Avith  a  deci-normal 
solution  of  nitrate  of  silver  (17  grm.  to  the  litre),  in 
the  presence  of  neutral  chromate  of  potassium.  The 
number  of  cubic  centimetres  of  the  silver  solution 
used  in   capsule   A    indicates   the   total    quantity  of 


HAYEM    AND    WINTER  6 1 

chlorine  originally  present  in  5  c.  c.  of  the  stomach 
contents.  Similarly,  the  number  of  cubic  centimetres 
used  in  capsule  B  represents  the  amount  of  chlorine 
remaining  after  evaporation  to  dryness — i.e.^  in  the  in- 
organic chlorides  and  the  hydrochloric  acid  combined 
with  proteids.  Capsule  C,  which  has  been  ignited 
without  the  addition  of  any  soda,  gives  the  amount 
of  the  inorganic  chlorides  in  5  c.  c.  of  the  stomach  con- 
tents. The  chlorine  is  rendered  in  terms  of  HCl  per 
cent. 

The  authors  also  estimate  the  total  acidity  in  the 
usual  way  with  phenol-phthalein  and  soda,  and  thus 
obtain  a  fourth  factor.  In  this  way  the  value  for  the 
total  chlorine  may  be  obtained,  and  if  the  figure 
pertaining  to  the  capsule  B  be  subtracted  from  that 
of  the  total  chlorine — i.e.,  that  in  capsule  A — the 
amount  of  free  hydrochloric  acid  may  be  calculated. 
Similarly,  by  subtracting  the  result  of  the  titration  in 
capsule  C  from  that  of  capsule  B,  the  hydrochloric  acid 
combined  with  proteids,  the  value  for  the  combined 
hydrochloric  acid,  may  be  ascertained.  The  values  of 
the  free  and  the  combined  acid  can  then  be  compared 
with  the  total  acidity  previously  estimated  ;  if  their 
sum  is  equal  to  or  above  it,  no  organic  acid  can  be 
present.  But  if  the  total  acidity  exceeds  the  figure 
obtained  by  the  sum  of  the  chlorine,  free  and 
combined,  organic  acid  or  acid  salts  must  also  be 
present  in  the  contents.  The  figure  obtained  in 
capsule  B  may  often  include  bodies  such  as  chloride 
of  ammonium,  which  are  driven  off  by  incineration, 
but  not  altogether  driven  off  at  lOO''  C,  and  thus 
increase  the  figure  obtained  for  the  combined 
chlorine. 


62  THE    METHOD    OF 

The  method  is,  unfortunately,  long,  and  the  mani- 
pulations required  difficult  of  accomplishment  save 
by  a  trained  chemist.  It  has  been  adversely  criticised 
by  many,  while  others  have  recommended  it  warmly. 
Biernacki  *  remarks  that  it  gives  correct  results  when 
used  in  artificial  digestion  experiments,  but  that  the 
figures  obtained  in  the  case  of  the  stomach  contents 
are  not  to  be  absolutely  relied  on,  especially  because  of 
the  presence  of  acid  phosphates.  Rosenheim  -J-  and 
Langermann  t  find  that  the  free  hydrochloric  acid  in 
the  stomach  contents  is  represented  as  too  small  in 
amount  by  it.  Hoffmann  §  condemns  all  methods  for 
the  estimation  of  free  hydrochloric  acid  by  evapora- 
tion as  liable  to  fallacy. 

Three  facts,  however,  can  be  absolutely  determined 
by  the  figures  obtained  from  the  method  of  Hayem 
and  Winter.  First,  the  total  quantity  of  hydro- 
chloric acid,  both  free  and  combined,  can  be 
accurately  deduced  from  the  chlorine  determinations 
in  the  first  and  third  capsules.  That  is  to  say,  that 
the  chlorine  originally  present  in  an  inorganic 
form  subtracted  from  the  total  chlorine  will  give  the 
exact  figure  for  the  chlorine  which  is  not  present  in  an 
inorganic  form.  Again,  the  figure  for  the  total  hydro- 
chloric acid  subtracted  from  the  total  acidity  will 
represent  without  error,  unless  ammonium  chloride 
be  present,  the  proportion  of  the  acidity  which  is  or  is 
not  due  to  it.  The  two  doubtful  values  are,  that  of  the 
free  hydrochloric  acid  {a  —  I?)  and  that  of  the  com- 

*  Ce7it}-alblatt  fiir  Klinische  M^dizin,  No.  20. 

■j-  Deutsche  Medizinische  Wochenschrift^  Nos.  13,  14,  1891. 

J  Virchow's  Arckiv,  Bd.  128. 

§  SchTaid^'sJahrbuc/i,  Bd.  233,  s.  268. 


HAYEM    AND    WINTER  6t, 

bined  hydrochloric  acid  (d  —  c),  although  the  sum  of 
the  two  may  be  correct. 

A  combination  of  this  method  and  the  method 
recommended  by  Mintz  yields  good  results.  By 
means  of  the  process  of  Hayem  and  Winter  the 
absolute  amount  of  chlorine,  which  is  not  in  the 
form  of  inorganic  compounds,  is  determined,  and 
then,  by  the  use  of  Mintz's  method,  the  amount  of 
free  hydrochloric  acid  is  ascertained.  The  difference 
between  the  two  values  will  give  the  figure  for  the 
free  acid. 

Hayem  and  Winter  designate  the  result  of  titration 
with  soda  solution,  that  is  the  total  acidity,  by  the 
letter  A  ;  the  total  chlorine,  "  chlore  total,"  by  T  ;  the 
difference  between  the  chlorine  in  crucibles  A  and  B, 
the  free  chlorine,  "  chlore  libre,"  by  H  ;  the  chlorine 
remaining  in  crucible  C  after  simple  incineration,  the 
inorganic  chlorine,  "  chlore  fixe,"  by  F;  and  the  excess 
of  chlorine  in  crucible  B  over  that  in  C  the  chlorine 
combined  with  proteids,  "  chlore  combine  organique,"" 
by  C.     Another  symbol  which  they  make  use  of  is  a, 

/A-  H^ 

'^  =  (^:-> 

The  symbol  a,  therefore,  represents  the  quotient  ob- 
tained by  dividing  the  figure  for  the  total  acidity, 
minus  that  for  free  hydrochloric  acid,  by  the  amount 
of  combined  chlorine.  If  no  organic  acids  are  present, 
or  acid  salts,  a  should  have  a  value  of  i.  Normally  it 
varies  between  0'8  and  0'g2. 

The  presence  of  the  organic  acids  of  fermentation 
and  of  an  excess  of  acid  salts  raises  the  value  of  A, 
and  thus  a  may  correspond  to  a  value  above  the 
figure  I. 


64  METHOD    OF    HAYEM    AND    WINTER 


Example  of  Hayem  and  Winter's  Method. 

Sample  of  stomach  contents  removed  two  hours  after  Benger's 
Food,  in  a  case  of  gastrostomy  for  occlusion  of  the  oesophagus. 

Contents  (slight  gastric  smell)  were  in  a  well-digested  form. 

After  filtering,  5  c.  c.  were  placed  in  three  crucibles — a,  b,  and 
c.  To  a  sodium  carbonate  was  added  in  excess.  The  three 
crucibles  were  then  heated  on  a  water-bath  until  an  hour  had 
elapsed  after  their  apparent  thorough  drying. 

Deci-normal  sodium  hydrate  solution  and  a  drop  of  phenol- 

phthalein  was  added  to  another  5  c.  c. 

N 
Total  acidity  =  6-5  c.  c.  NaHO — ,  or  0-4745  per  cent,  or  130. 

10 

The  dried  contents  of  crucible  b  were  dissolved  in  a  little 
distilled  water,  carbonate  of  soda  added,  and  the  solution  dried 
again  as  before. 

The  contents  of  a,  b,  and  c  were  now  ignited  over  a  naked 
flame  at  a  dull  red  heat,  the  resulting  ash  dissolved  in  water, 
rendered  slightly  acid  with  nitric  acid,  heated  to  expel  carbonic 
acid,  and  filtered. 

The  filtrates  were  titrated  with  deci-normal  nitrate  of  silver 
solution,  and  chromate  of  potassium. 

a.  Total  chlorine,         .  6'6  c.  c.  A0NO3  — ,  or  0-4818  per  cent. 

b.  Chlorine  after  eva- 

poration,     .         .   6-0  c.  c.       ,,  „   or  0-4380         „ 

c.  Inorganic  chlorine, .  1-6  c.c.       ,,  ,,   or  o"ii68         „ 


1.  Total  acidity,  ....  0-4745  per  cent,  or  130  =  A 

2.  Total  chlorine  {a),  .         .         .  0-4818         „  =  T 

3.  Free  chlorine  ((Z  —  i5)        .         .  0-0438         „  =H 

4.  Fixed  chlorine  (c)  .         .         .  o-ii68         ,,  =  F 

5.  Combined  chlorine  {b—c)        .  0-3212         „  =  C 

6.  Acidity  not   due   to   chlorine 

(1-3+  5),  •         •         •         •  0-1095  or  30. 
^A— H>^  _  0-4745-0-0438  ^  ^ 


(^)  = 


0-3212 


toepfer's  method  65 

The  figures  obtained  show  practically  normal  amounts  of 
chlorine,  and  a  high  total  acidity,  much  of  it  not  due  to  hydro- 
chloric acid.  7'his  circumstance  is  explained  by  the  fact  that  the 
patient  at  the  time  was  taking  dilute  phosphoric  acid  after  her  food. 

{d.)  Toepfers  Method. — A  method  has  been  de- 
scribed by  Toepfer  *  which  is  easily  performed,  and 
is  said  to  be  fairly  accurate.  Toepfer  first  estimates 
the  total  acidity  by  means  of  phenol-phthalein  and  a 
deci-normal  solution  of  soda  in  the*usual  way-f  He 
then  uses  a  i  per  cent,  solution  of  sodium-alizarin- 
sulphonate  in  water.  This  body  is  stated  to  be 
unaffected  by  hydrochloric  acid  in  combination  with 
proteid.  A  third  indicator  is  also  used,  0*5  per  cent, 
solution  of  dimethyl -amido-azo -benzol  in  alcohol, 
which  reacts  to  free  mineral  acids,  and  is  not  affected 
by  organic  acids,  unless  present  in  greater  pro- 
portion than  0"5  per  cent.  The  second  reagent  is 
termed  for  brevity  alizarin,  and  is  used  in  a  similar 
manner  to  phenol-phthalein,  deci-normal  soda  being 
added  until  a  permanent  pure  violet  colour  results. 
This  tint  should  be  compared  with  that  formed  on 
the  addition  of  3  or  4  drops  of  the  alizarin  solution  to 
5  c.  c.  of  a  I  per  cent,  solution  of  sodium  carbonate. 
The  third  indicator,  or  dimethyl,  has  a  yellow  colour 
if  no  free  hydrochloric  acid  be  present,  red  if  there 
be  some  in  the  contents.  The  deci-normal  solution 
is  added  until  this  red  colour  disappears.  By  this 
method  we  obtain,  first,  the  total  acidity ;  second, 
with  the  alizarin,  the  acidity  minus  the  combined 
hydrochloric  acid.  No.  2  subtracted  from  No.  i  gives 
the  amount  of  combined  hydrochloric  acid  present. 

*  Zeitschr.f.  Phys.  Chernie^  Bd.  xix.,  pp.  104-222. 
t  But  see  p.  68. 

E 


66  toepfer's  method 

The  amount  of  soda  used  in  titrating  No.  3  gives  the 
free  hydrochloric  acid.  Adding  the  figures  obtained 
for  the  combined  and  the  free  hydrochloric  acid  will 
give  the  total  proportion  of  that  acid  present ;  and 
subtracting  that  from  the  total  acidity  will  give  the 
acidity  due  to  organic  acids  and  acid  salts. 

The  advantages  of  this  method  are,  that  it  takes  up 
a  short  time  and  requires  no  complicated  apparatus, 
the  addition  of  the  soda  solution  to  equal  parts  of  the 
contents  after  the  addition  of  the  three  indicators 
being  all  that  is  necessary.  With  regard  to  Toepfer's 
method,  Mohr  *  states  that  good  results  may  be  ob- 
tained after  the  operator  has  had  some  practice  with 
it,  but  that  at  first  it  is  difficult  to  decide  the  exact 
point  at  which  the  end  reactions  occur.  There  is  a 
danger,  to  his  mind,  of  the  quantity  of  free  hydro- 
chloric acid  found  being  too  high. 

Hoppe-Seyler  f  recommends  it,  while  Strauss  | 
remarks  that  the  end  reaction  with  the  dimethyl  is 
determined  with  difficulty. 

Hari,  §  discussing  it,  is  not  quite  sure  if  the  alizarin 
is  to  be  absolutely  depended  upon  for  the  estimation 
of  the  combined  hydrochloric  acid,  while  he  recom- 
mends the  portion  to  which  this  indicator  has  been 
added  to  be  shaken  thoroughly  until  the  violet  colour 
produced  by  the  alkali  has  disappeared,  when  a  thin 
layer  of  the  fluid  is  looked  through.  Dimethyl-amido- 
azo-benzol  appears  to  be  ten  times  more  delicate 
than  Gunzburg's  reagent  and  than  Congo  red,  in  the 

*  Zeitschrift f.  Phys.  Chemie^  Bd.  xix.,  No.  6,  p.  647. 

i"  Miinchener  Med.  Wochensc/irift,  1.,  1895. 

J  Deutsche  Arch.f.  klin.  Med.,  Ivi.,  p.  I,  287. 

§  Archivf.  Verdauwigskrankkeiten,  Bd.  ii.,  Heft  2. 


toepfer's  method  67 

detection  of  free  h}'drochloric  acid,  and  twenty  times 
more  delicate  than  Congo  red  with  regard  to  organic 
acids. 

The  experience  of  this  method  which  the  writer  has 
had  does  not  lead  him  to  recommend  it  as  being  very 
accurate.  The  presence  of  free  organic  acids  along 
with  free  hydrochloric  acid  causes  the  dimethyl  to 
record  too  high  a  figure,  in  the  same  way  as  Gunzburg's 
reagent ;  while  he  cannot  accept  it  as  proved  that  it  is 
entirely  uninfluenced  by  hydrochloric  acid  in  proteid 
combinations.  Artificial  mixtures  of  albumin  with  a 
very  small  portion  of  hydrochloric  acid,  which  did  not 
lose  acidity  on  drying,  and  in  which  both  Gunzburg's 
and  Liebermann's  tests  were  negative,  coloured  the 
dimethyl  solution  pink  or  orange,  and,  if  this  reagent 
be  accurate,  contained  some  free  mineral  acid.  It  is 
so  delicate,  as  regards  free  hydrochloric  acid,  that  it  is 
almost  certain  that  it  must  react  in  some  degree  to 
that  acid  in  its  combined  form. 

Its  end  reaction  is  also  difficult  to  determine  with 
certainty.  If  a  drop  be  added  to  5  c.  c.  of  deci-normal 
hydrochloric  acid  solution,  and  an  exactly  correspond- 
ing amount  of  deci-normal  solution  of  soda  added, 
before  the  acid  has  been  neutralised,  the  bright  red 
colour  changes  to  orange,  then  to  brownish  yellow, 
becoming  light  yellow  on  exact  neutralisation.  This 
light  yellow  tint  must,  therefore,  be  reached  in  titrat- 
ing specimens  of  stomach  contents  before  the  absence 
of  free  hydrochloric  acid  is  certain.  But  the  orange 
colour  mentioned  above  seems  to  be  given  to  the  dye 
by  dilute  organic  acids,  and  by  combined  hydrochloric 
acid. 

Sodium-alizarin-sulphonate  is  supposed  to  be    un- 


68  toepfer's  method 

affected  by  this  combined  hydrochloric  acid,  while 
reacting  to  all  other  acid  bodies.  When  tested  in  the 
same  way  as  dimethyl,  its  colour,  greenish  yellow  in 
the  presence  of  acids,  became  violet  at  the  point  of 
neutralisation,  using  deci-normal  solutions  of  hydro- 
chloric acid  and  soda.  With  excess  of  proteid,  the 
violet  colour  did  not  appear  until  a  considerable 
quantity  of  alkali  was  added,  more  than  was  repre- 
sented by  any  acid  salts  in  the  albumin  solution,  or 
free  acid  as  shown  by  dimethyl. 

Toepfer  recommends  that  the  titration  with  phenol- 
phthalein  and  deci-normal  soda  should  be  carried  on 
until  the  colour  produced  is  not  deepened  by  further 
addition,  instead  of  regarding  the  first  permanent  pink 
tinge  as  the  end  reaction.  Equal  quantities  of  acid  and 
alkaline  deci-normal  solutions  when  mixed  together 
produce  no  coloration  of  phenol-phthalein,  a  trace  of 
the  soda  in  excess  causes  a  permanent  pink,  the  depth 
of  which  varies  greatly  with  the  quantity  added.  A 
dark  red  only  appears  when  the  fluid  is  of  considerable 
alkalinity,  while  excess  of  the  indicator  yields  a  perman- 
ent degree  of  redness  where  the  usual  smaller  quantity 
only  gives  a  pink,  capable  of  further  intensification. 

Example  of  Tocpfej's  Method. 
Contents  removed  from  a  case  of  slight  excess  of  h3'drochloi  ic 
acid,  two  hours  after  a  light  meal.     Have  no  smell,  fluid  clear, 
food  well  digested.     Used  unfiltered. 

r.   Total  acidity. 

10  c.  c.  titrated  with  deci-normal  soda  and  phenol-ptha- 

lein. 
8' I  c.  c.  used  until  solution  became  pink — 

8'i  X  o'oo365  =  o"295  per  cent.,  or  8x. 
8'5  c.  c.  used  until  solution  became  red — 

8'5  X  o'oo365  =  o'3io  per  cent.,  or  85. 


toepfer's  method  69 

2.  Free  hydrochloric  acid. 

10  c.  c.  titrated  with  deci-normal  soda  and  2  drops  of  0-5 
per  cent,  alcoholic    solution    of    dimethyl-amido-azo- 
benzol. 
4'6  c.  c.  added  when  solution  became  orange — 

=  0"i679  per  cent.,  or  46. 

5*1  c.  c.  added  when  solution  became  light  yellow — 

=  0'i86i  per  cent,  or  51. 

3.  Acidity  minus  tJiat  due  to  combined  hydrochloric  acid. 

10  c.  c.  and  3  drops  of  the  watery  solution  of  alizarin- 
sodium-sulphonate  :  titrated  as  above. 

7'8  c.  c.  used  before  solution  became  violet  and  corre- 
sponded to  tint  of  the  indicator  in  a  3  percent,  solution 
of  sodium  carbonate — • 

7"3  c.  c.  X  0-00365  =0-2847  per  cent.,  or  78. 


Result. 


j  0-295  per  cent.,  or  81 


Total  acidity       i        ^    '  ^        (0 

•^        (.0-310        ,,  ■^"      ^  ^ 


5:5 


Combined  HCl  I  °'°^°^  "  "      l  (1-3) 

1 0-0255  „  „      7  ^     ^' 

Organic  acids       (  o-ii68  ,,  ,,-  32  r        .       x-, 

and  acid  salts  (  0-0985  ,,  „    27  ^-^K     ^n 


Total  hydrochloric       j  0-1782  per  cent,  or  49 
acid,  free  and  combined  (  0-2 1 16        ,,  „    58'-"     ^     3jJ 

Phloroglucin-vanillin  gave  the  free  HCl  as  only  0-09  per  cent. 

(^.)  Martins  and  Lilttkes  Method. — This  method  is 
based  upon  the  theory  that,  when  the  gastric  contents 
are  ignited  at  a  low  heat,  below  the  point  at  which 
chlorides  volatilise,  the  hydrochloric  acid  present  is 
driven  off,  leaving  the  chlorine  which  is  in  combination 
with  bases.     It,  in  fact,  rests  upon  the  same  proposi- 


JO  MARTIUS    AND    LUTTKE  S    METHOD 

tion  which  Hayem  and  Winter  have  advanced  for  part 
of  their  process.  The  only  difference  hes  in  the  fact 
that  the  dried  contents  are  not  subjected  to  so  high 
a  temperature.  Indeed,  the  method  has  been  elabo- 
rated for  the  purpose  of  estimating  the  chlorine  present 
without  destroying  the  organic  substances  which  are 
contained  in  the  fluid  tested. 

Reagents  required  (Volhard's  Method). 

1.  A  deci-normal  silver  solution,  containing  nitric  acid  and 
persulphate  of  iron. 

This  solution  is  made  by  dissolving  16-997  grm.  of  dried  and 
pure  nitrate  of  silver  in  about  900  c.  c.  of  dilute  nitric  acid,  con- 
taining "25  per  cent,  of  the  acid,  adding  50  c.  c.  of  the  liquor 
ferri  persulphatis,  and  diluting  the  mixture  with  distilled  water 
to  the  volume  of  1000  c.  c.  10  c.  c.  of  this  solution  represents 
0'0365  grm.  HCl. 

2.  A  deci-normal  solution  of  ammonium  sulphocyanide. 

7*6  grm.  of  this  salt  is  dissolved  in  distilled  water  and  the 
solution  made  up  to  1000  c.  c.  The  solution  must  be  stand- 
ardised against  the  foregoing  solution  of  nitrate  of  silver. 

To  do  this  10  c.  c.  of  the  silver  solution  are  measured 
out  into  a  beaker  and  about  200  c.  c.  of  water  added.  The 
sulphocyanide  solution  is  then  added  from  a  burette  until  a 
permanent  reddish  colour  appears.  If  the  solutions  are  exactly 
correct,  10  c.  c.  of  the  sulphocyanide  solution  will  be  neces- 
sary. If,  say,  9'6  c.  c.  are  required,  960  c.  c.  of  the  sulphocyanide 
solution  must  be  diluted  up  to  1000  c.  c.  This  diluted  solution 
should  again  be  tested  against  the  deci-normal  silver. 

The  Process  of  Analysis. 

10  c.  c.  of  the  unfiltered  stomach  contents  are  poured 
into  a  graduated  flask  of  100  c. c.  capacity.  The  con-- 
tents  should  be  well  shaken  before  being  measured. 
Then  20  c.  c.  of  the  deci-normal  acid  silver  solution 
are   added  to   this,   the    whole  well  shaken  and  set 


MARTIUS    AND    LtJTTKE  S    METHOD  7  I 

aside  for  ten  minutes.  If  the  contents  are  strongly 
coloured,  they  may  be  decolorised  by  the  addition  of 
5  to  lo  drops  of  a  solution  containing  i  part  of 
potassium  permanganate  in  15  parts  of  water.  This 
is  rarely  necessary,  and  the  addition  should  only  be 
made  after  all  the  chlorine  has  combined  with  the 
silver,  as  permanganate  of  potash  decomposes  free 
hydrochloric  acid  and  liberates  chlorine.  After 
chlorine  has  combined  with  silver  this  action  does 
not  occur.  The  contents  of  the  flask  are  then  diluted 
with  distilled  water  to  the  100  c.  c.  mark,  and  filtered 
through  a  dry  filter  paper  into  a  dry  vessel.  50  c.c. 
of  the  filtrate  are  placed  in  a  beaker,  and  the 
quantity  of  silver  is  determined  by  the  use  of  the 
sulphocyanide  solution.  The  number  of  c.c.  of  this 
solution  used  is  multiplied  by  2,  and  the  figure  ob- 
tained is  subtracted  from  the  20  c.c.  of  silver  solution 
originally  employed,  and  gives  the  amount  of  silver  re- 
quired to  combine  with  the  total  chlorine,  and,  there- 
fore, the  amount  of  total  chlorine  in  10  c.  c.  of  the  gastric 
contents.  The  sulphocyanide  solution  is  acted  on  by 
the  nitrate  of  silver  uncombined  with  chlorine,  and  is 
unaffected  by  the  chloride  of  silver  formed  from  the 
chlorine  in  the  stomach  contents.  This  part  of  the 
process  gives  the  total  quantity  of  chlorine  present  in 
the  contents. 

Other  10  c.c.  of  the  gastric  contents  are  evaporated 
to  dryness  in  a  platinum  capsule  either  on  a  water- 
bath  or  an  asbestos  slab.  They  are  then  ignited  over  a 
naked  flame  until  the  residue  no  longer  burns  with  a 
luminous  flame,  care  being  taken  not  to  heat  the  cap- 
sule too  strongly  and  to  thereby  drive  off  some  of  the 
chlorine.     After  the  incineration  the  residue  is  mois- 


72  MARTIUS    AND    LUTTKE  S    METHOD 

tened  with  distilled  water  and  thoroughly  rubbed  up 
with  it  by  means  of  a  glass  rod.  It  is  then  treated  with 
hot  distilled  water  and  filtered,  the  precipitate  on  the 
filter  being  washed  once  or  twice  with  hot  water  to 
make  sure  that  all  the  chlorides  have  been  removed 
from  the  carbon  and  insoluble  ash  of  the  residue. 
The  whole  filtrate  is  then  mixed  with  lo  c.  c.  of  the 
deci-normal  silver  solution,  and  the  excess  of  silver 
nitrate  remaining  determined,  as  before,  by  means  of 
the  sulphocyanide  solution.  The  figure  obtained, 
subtracted  from  the  lo  c.  c.  of  the  silver  solution 
originally  added,  gives  the  amount  of  silver  required 
to  combine  with  the  chlorine  in  the  inorganic  chlorides 
of  10  c.c.  of  the  gastric  contents. 

From  the  first  analysis  we  have  found  the  total 
chlorine  present,  in  the  second  the  chlorine  which  is 
in  the  form  of  inorganic  salts.  If  the  second  figure  be 
subtracted  from  the  first,  we  obtain  the  exact  amount 
of  chlorine  present  in  the  form  of  hydrochloric  acid  in 
lo  c.c.  of  the  gastric  contents. 

Example  of  Martius  and  Liittke's  Method. 

Stomach  contents  from  a  case  of  chronic  fermentative  dys- 
pepsia with  intestinal  putrefaction ;  sour  smell ;  food  ill-digested; 
a  number  of  organisms  under  the  microscope  ;  removed  two  and 

a  half  hours  after  a  liffht  breakfast. 


Total  Acidity  =  0"25  per  cent.,  or  yo  (unfiltered). 
No  free  hydrochloric  acid  present  with  vanillin-phloroglucin. 
Acetic  and  lactic  acids  present  with  Uffelmann's  reagent. 

10  c.c.  of  unfiltered  contents  were  placed  in  a  loo  c.c.  flask, 
and  20  c.c.  of  the  deci-normal  and  silver  solution  added.  After 
diluting  to  lOO  c.c.  and  filtering,  50  c.c.  were  titrated  with  the 
deci-normal  ammonium  sulphocyanide  solution. 


MARTIUS    AND    LUTTKE  S    METHOD  J ^^ 

6'2  c.  c.  were  added  before  a  permanent  reddish  colour  ap- 
peared. 

That  is,  I2"4  c.  c.  of  the  silver  solution  were  contained  in  the 
filtrate  of  loo  c.  c,  but  20  c.  c.  were  added,  7*6  c.c.  therefore 
remained  on  the  filter  paper. 

7'6  c.c.  =  (i  c.  c.  =  0"00365  grm.  HCI)  0-02774  gi'™-  HCl  in 
10  c.  c,  or  0*02774  per  cent. 

The  total  chlorine  present  was  0-2774  P^'"  cent. 

Other  10  c.c.  were  dried  in  a  crucible  and  carbonised  over  a 
naked  flame.  The  residue  was  well  washed  with  distilled  water 
and  filtered.  10  c.  c.  of  the  acid  silver  solution  were  added,  and 
the  amount  made  up  to  100  c.c.  After  filtration,  50  c.c.  were 
taken  and  titrated  as  above. 

2"5  c.c.  of  the  sulphocyanide  solution  were  required,  or  5  c.  c. 
in  the  100  c.  c.  5  c.  c.  subtracted  from  the  original  10  c.  c  of 
the  silver  solution  left  5  c.  c.  remaining  on  the  filter  as  chloride 
of  silver,  or  OT825  per  cent,  as  hydrochloric  acid. 

The  inorganic  chlorine  present  was  o-i825  per  cent. 

Result — - 

Total  acidity,         .  .  .  o"25  per  cent. 

Total  chlorine,      .  .  .  0*2774     » 

(Free  chlorine,  o-oo  per  cent.) 

Inorganic  chlorine,  .  .  o'i825  per  cent. 

Chlorine  combined  with  proteids,       0-0949       „ 
Therefore, 

Acidity  due  to  other  factors,        .  0-J551     ,, 

The  results  from  this  analysis  were  checked  by  using  25  c.c. 
of  the  two  filti-ates  which  remained,  adding  to  them  dilute 
hydrochloric  acid  in  excess,  and  throwing  the  chloride  of  silver 
formed  on  ash-free  filter  papers.  The  precipitates  were  then 
washed  with  water  and  alcohol,  dried,  incinerated  in  weighed 
capsules,  and  the  amount  of  chloride  of  silver  present  deter- 
mined by  weighing.  The  precipit;ite  of  chloride  of  silver  was 
so  finely  divided  that  some  sodium  chloride  had  to  be  added  in 
addition  to  the  acid,  and  the  precipitate  on  the  filter  could  not 
be  thorough!}'  washed.  After  incineration,  therefore,  when  the 
silver  chloride  remained  in   a  more  compact  state,  any  soluble 


74      MARTIUS  AND  LUTTKe's  METHOD 

chlorides  present  were  washed  awa}^  with  distilled  water,  before 
finall}^  drying  and  weighing. 

Thus  in  the  estimation  of  the  total  chlorine  the  20  c.  c.  of  the 
silver  solution  added  represents  0-34  grm.  AgNOj  or  0-287  gfm. 
AgCl  (170  :  I43'5).  In  25  c.  c.  of  the  filtrate  -0438  grm.  of  silver 
chloride  was  found,  or  0'i752  grm.  in  the  100  c.c.  Subtract- 
ing this  from  0-287  grm.  we  get  o-iiiS  grm,  of  silver  chloride, 
which  corresponds  to  the  chlorine  left  on  the  filter  paper  in 
10  c.c.  of  the  contents. 

0-1118x0-25427  =  0-028427  grm.  HCl  in  10  c.c,  or  0-2842 
per  cent. 

From  25  c.c.  of  the  second  filtrate,  o-oi8  grm.  of  chloride  of 
silver  was  obtained,  or  0*072  in  the  total  fluid,  to  which  10  c.c. 
of  the  silver  nitrate  solution  had  been  added,  equal  to  0-1435 
grm.  AgCl. 

The  amount  of  AgCl  remaining  on  the  filter  paper  was  therefore 
0-1435-0-072  =  0-0715.  This  multiplied  as  above  gives  0-1807 
per  cent.,  for  the  inorganic  chlorides  as  HCl. 


Resiclt. 

Titration.  Gravimetric. 

Total  chlorine,     .         .  0-2774  P^'"  cent.         0-2842  per  cent. 
Inorganic  chlorine,       .  0-1825        ,>  0-1807       ,, 

Hydrochloric  acid,       .  0-0949        ,,  0-1035       „ 

(/[)  The  Auihoj'S  Method.  —  This  method  was 
devised  as  a  simple  and  ready  means  of  obtaining 
most  of  the  information  afforded  by  the  many  and 
complicated  chemical  manoeuvres  of  the  two  pre- 
ceding methods.  Instead  of  estimating  the  chlorine, 
as  Hayem  and  Winter  recommend,  the  acidity  before 
and  after  evaporation  is  determined.  Ten  c.  c.  of  the 
filtered  or  unfiltered  gastric  contents  are  placed  in  an 
evaporating  basin,  and  other  10  c.  c.  in  a  beaker.  The 
evaporating  basin  is  placed  on  a  water-bath  and  the 
contents  evaporated  to  dryness  at  the  boiling  point. 
The   basin    is  left   for   an   hour   or   more    after   the 


author's  clinical  method  75 

contents  seem  to  be  dry.  A  small  quantity  of 
distilled  water  is  then  added,  and  a  drop  of  the 
solution  tested  with  vanillin-phloroglucin.  If  free 
hydrochloric  acid  be  shown  to  be  still  present,  it  is 
again  evaporated.  In  cases  where  there  is  much 
proteid  material  and  a  high  percentage  of  free  hydro- 
chloric acid,  it  is  as  well  to  add  water  to  the  dried 
residue  and  evaporate  again  at  least  three  times. 
Ultimately  the  dried  residue  is  dissolved  in  distilled 
water  and  well  stirred.  The  total  acidity  of  the 
lo  c.  c,  previously  placed  in  a  beaker,  is  determined 
by  means  of  a  deci-normal  soda  solution  and  phenol- 
phthalein.  The  acidity  of  the  lo  c.  c,  which  have 
been  dried  and  re-dissolved  in  water,  is  similarly 
determined,  and  gives  the  acidity  remaining  after 
volatilisation  of  any  free  volatile  acid.  Numerous 
determinations  of  the  results  of  this  method,  performed 
upon  artificial  digestive  mixtures,  show  that  the  results 
obtained  are  very  accurate.  In  the  practical  analysis 
of  the  gastric  contents,  the  total  acidity  may  be  com- 
posed of  hydrochloric  acid  in  its  two  forms,  volatile 
organic  acids,  non-volatile  lactic  acid,  and  acid  salts. 
The  acidity  of  the  portion  after  evaporation  may 
be  made  up  of  combined  hydrochloric  acid,  lactic 
acid,  and  acid  salts.  As  a  rule,  if  there  is  much 
free  hydrochloric  acid  present,  the  organic  acids 
are  either  absent,  or  present  in  very  small  quantities. 
When  the  contents  in  the  evaporating  basin  are 
heated,  the  volatile  fatty  acids,  such  as  acetic  and 
butyric  acids,  are  first  driven  off.  Free  hydrochloric 
acid,  however,  does  not  volatilise  until  almost  all 
the  water  has  disappeared.  In  fact,  before  the  end 
of  the    evaporation,    if    free    hydrochloric    acid    be 


76  author's  clinical  method 

present,  it  becomes  so  concentrated  that  any  proteid 
bodies  in  the  contents  are  charred.  This  char- 
ring develops  a  dark  violet  coloration  which  is 
known  as  Liebermann's  reaction,  and  serves  to  indi- 
cate, almost  as  well  as  Giinzburg's  test,  the  presence 
of  the  acid  in  a  free  state.  The  violet  colour  is  prob- 
ably due  to  the  formation  of  a  colouring  matter,  from 
the  proteids  present,  similar  to  the  body  known  as 
tryptophan,  one  of  the  normal  products  of  the 
tryptic  digestion  of  albuminous  bodies.  Hydrochloric 
acid  forms  a  combination  with  this  pigment. 

We  have  now  obtained  the  acidity  of  the  10  c.  c. 
which  have  been  dried,  and  that  of  the  10  c.  c.  before 
evaporation.  If  the  figure  for  the  acidity  after  evapo- 
ration be  smaller  than  that  obtained  in  the  other 
portion,  some  acid  must  have  been  driven  off  during 
the  process  of  evaporation.  If  this  be  hydrochloric 
acid,  a  violet  coloration  of  the  dried  residue  ap- 
pears ;  if  it  be  due  solely  to  volatile  fatty  acids,  no 
such  change  in  colour  results.  If  the  acidity  of  the 
two  portions,  before  .  and  after  evaporation,  be  the 
same,  no  volatile  acid  can  be  present. 

It  is  not  contended  that  this  procedure  is  absolutely 
accurate,  but  it  affords  an  easy  and  rapid  way  by  which 
the  constituents  which  go  to  form  the  acidity  of  the 
gastric  contents  can  be  ascertained.  The  evaporation 
of  the  second  portion  can  be  carried  out,  if  no 
water-bath  is  handy,  on  the  top  of  hot  pipes,  such 
as  are  used  for  heating  purposes,  or  an  ordinary  pan 
may  be  half  filled  with  water,  boiled  on  a  gas  jet,  over 
or  close  to  a  fire,  and  the  porcelain  basin  containing 
the  contents  floated  on  the  surface  of  the  water.  No 
doubt  some  time  elapses  before  the  portion  is  thor- 


AUTHORS    CLINICAL    METHOD  "]"] 

oughly  dried,  but  while  it  is  drying  one  can  easily 
attend  to  other  matters,  as  the  evaporation  requires 
little  or  no  actual  supervision. 

Now  let  us  consider  what  information  we  have 
derived  from  the  results  of  the  analysis  in  this  process. 
\A''e  have  estimated  the  total  acidity  of  the  stomach 
contents;  we  have  determined,  more  or  less  accurately, 
the  amount  of  acid  which  is  volatile ;  and  we  have 
remaining  the  proportion  of  acid  which  cannot  be 
driven  off  by  heating  to  dryness  at  the  boiling  point. 
We  have  been  afforded  evidence  by  the  presence  or 
absence  of  Liebermann's  reaction  whether  free  hydro- 
chloric acid  is  contained,  or  not,  in  the  specimen 
analysed.  No  one  can  cavil  at  the  result  obtained 
from  the  estimation  of  the  total  acidity,  while  even  if 
the  proportion  for  the  free  acid  obtained  be  a  little 
over  or  slightly  under  the  real  amount,  we  have 
learned  whether  it  contains  any  hydrochloric  acid,  or 
only  volatile  fatty  acids.  The  acidity  remaining  after 
evaporation  can  only  consist  of  hydrochloric  acid  com- 
bined with  proteid  bodies,  lactic  acid  and  acid  salts. 
The  presence  of  lactic  acid  in  such  quantity  as  to 
indicate  abnormal  chemical  changes  during  the  course 
of  gastric  digestion,  may  easily  be  determined  by 
means  of  Uffelmann's  test,  or  any  of  the  other  tests 
detailed  under  the  section  in  which  the  methods  of 
detecting  this  acid  are  detailed  (page  43).  The  acid 
salts  are  seldom  present  in  sufficient  quantity  to 
vitiate  any  arguments  based  on  the  quantity  of  non- 
volatile acidity  found  in  this  way.  If  the  tests  for 
lactic  acid  be  negative,  or  if  they  give  only  a 
slight  reaction,  the  acidity  remaining  after  evapora- 
tion may  be  regarded  as  almost  entirely  consisting  of 


yS  author's  clinical  method 

hydrochloric  acid  in  combination  with  proteid  bodies. 
The  free  acid — that  is,  the  acid  driven  off  during  the 
process  of  evaporation — may  of  course  consist  of  both 
hydrochloric  acid  and  volatile  fatty  acids.  It  is 
well  to  remember,  as  already  mentioned,  that  the 
presence  of  free  hydrochloric  acid,  within  normal 
limit,  generally  contra-indicates  the  presence  of  fatty 
acids  due  to  fermentative  changes.  Thus,  if  by  means 
of  Giinzburg's  reagent,  or  by  the  colour  produced  by 
drying,  a  considerable  percentage  of  free  hydrochloric 
acid  is  shown  to  be  present,  a  trace  of  the  fatty  acids 
means  little.  On  the  other  hand,  a  trace  of  the  free 
mineral  acids  with  a  considerable  proportion  of  free 
acidity  may  indicate  the  occurrence  of  fermentative 
changes  due  to  the  presence  of  the  mineral  acid  in 
insufficient  quantity  to  exercise  antiseptic  influences. 
The  tests  already  mentioned  on  page  45  will  serve  to 
indicate  whether  these  volatile  fatty  acids  are  present 
in  any  large  amount. 

The  significance  of  the  amounts  of  free  hydrochloric 
acid,  and  of  that  acid  in  combination  with  proteid 
bodies,  lies  in  the  fact  that  the  free  acid  may  be 
looked  upon  as  an  active  force  in  further  digestion, 
and  in  the  prevention  of  fermentative  changes  ;  while 
the  combined  portion  of  this  acid  represents  the 
amount  of  work  done, — the  expended  force, — towards 
the  digestion  of  the  proteids  contained  in  the  food. 
Any  conclusions  based  upon  the  proportions  of  these 
two  forms  in  which  the  hydrochloric  acid  is  found 
must  include  the  consideration  of  the  time  after  the 
last  meal  and  the  characters  of  the  food  taken  in  it. 

But  this  method  is  capable  of  further  expansion. 
If  the  acidities  be  determined  in  fireproof  porcelain 


AUTHOR  S    CLINICAL    METHOD  79 

crucibles,  and  a  third  portion  of  the  contents  (lo  c.  c.) 
be  placed  in  another  crucible,  the  total  chlorine  present 
can  be  determined  after  the  total  acidity  has  been  cal- 
culated in  portion  No.  i  by  adding  a  small  excess  of 
carbonate  of  soda,  and  then  by  drying  the  contents  on  a 
water-bath,  incinerating  at  a  dull  red  heat,  and  deter- 
mining the  amount  of  chlorine  present  in  the  residue 
in  the  usual  way  {vide  Hayem  and  Winter,  page  59). 

After  estimating  the  acidity  contained  by  the  10  c.c. 
in  crucible  No.  2, — that  is,  the  acidity  after  eva- 
poration,— carbonate  of  soda  may  likewise  be  added, 
and  the  chlorine  which  remains  calculated  as  in  the 
last. 

In  the  third  crucible  the  contents  are  simply  dried 
without  any  addition,  incinerated  as  before,  and  the 
amount  of  chlorine  in  the  ash  determined. 

If  it  is  wished  to  find  out  the  percentage  of  solids 
in  the  contents,  crucible  No.  3  may  be  weighed  before- 
hand, weighed  after  the  10  c.c.  have  been  thoroughly 
dried,  and  again  after  incineration.  The  difference 
between  the  second  weighing  and  the  first  gives  the 
amount  of  total  solids  in  10  c.c. ;  the  first  weighing 
subtracted  from  the  third  gives  the  percentage  of  ash  ; 
while  the  ash  deducted  from  the  total  solids  gives  the 
proportion  of  organic  material  present. 

The  determination  of  the  chlorine  is  thus  very 
similar  to  the  method  advocated  by  Hayem  and 
Winter,  or  by  Martius  and  Liittke.  The  heat  employed 
in  the  incineration  of  the  contents  of  the  crucibles 
should  never  be  raised  above  that  of  a  dull  red  ;  if 
this  degree  of  heat  be  continued  for  some  time  and  not 
exceeded,  the  carbon  of  the  residue  may  be  driven  off 
without  volatilisation  of  the  inorganic  chlorides.     The 


8o  author's  clinical  method 

process  of  incineration  in  the  first  and  second  crucibles 
need  not  go  so  far  as  this,  nor  need  the  carbon  be 
altogether  driven  off  from  a  third  crucible,  unless  it 
is  wished  to  obtain  the  exact  amount  of  inorganic  ash 
present  in  the  contents. 

Owing  to  the  addition  of  the  excess  of  soda  before 
drying  and  incinerating  the  first  two  specimens,  the 
residue  remaining  after  incineration  is  strongly  alka- 
line, and,  therefore,  after  solution  in  distilled  water, 
should  be  carefully  neutralised  by  the  addition  of 
dilute  nitric  acid,  to  prevent  any  fallacy  arising  from 
the  presence  of  phosphates  and  to  facilitate  the  dis- 
integration of  the  ash.  If  the  amount  of  carbon 
left  after  incineration  be  considerable,  it  tends  to 
render  the  end  reaction  of  the  quantitative  test  for 
chlorine,  by  means  of  silver  nitrate  and  chromate  of 
potassium,  indefinite  and  difficult  to  determine  with 
exactitude.  In  such  a  case,  after  adding  distilled 
w^ater  to  the  residue,  it  may  be  thrown  upon  a  filter, 
washed  several  times  with  distilled  water  to  extract  all 
the  chlorine,  and  the  filtrate  tested  without  the  carbon 
which  has  been  left  on  the  filter  paper.  It  may  be 
advisable,  in  such  a  case,  to  use  Volhard's  method  in 
the  estimation  of  the  chlorides,  a  method  w^hich  has 
been  already  described  in  the  consideration  of  IMartius 
and  Liittke's  process. 

The  figures  obtained  from  these  processes  represent 
the  total  chlorine  present  in  lO  c.c.  (crucible  No.  i) ;  the 
chlorine  left  in  the  contents  after  evaporation  at  ioo°  C. 
(crucible  No.  2);  and  the  proportion  of  chlorine  present 
in  the  form  of  inorganic  compounds  with  bases.  As 
in  the  process  of  Hayem  and  Winter,  the  figure 
obtained  from  crucible  No.  2  when  subtracted  from 


author's  clinical  method  8 1 

that  of  crucible  No.  i  gives  the  quantity  of  chlorine 
driven  off  by  evaporation  ;  while  the  figure  which 
represents  the  inorganic  chlorine,  obtained  from 
crucible  No.  3,  if  subtracted  from  that  of  crucible 
No.  2,  will  give  the  amount  of  chlorine  which  has  not 
been  driven  off  by  drying  at  the  boiling  point,  but 
which  is  burned  off  during  incineration. 

The  figures  obtained  in  the  two  sections — that  is, 
those  for  the  acidities  and  those  for  the  chlorine — may 
with  advantage  be  expressed  in  each  case  in  terms  of 
hydrochloric  acid  per  cent.  They  are  then  exactly 
comparable,  and  the  amount  of  free  acid  can  be  con- 
trasted with  that  of  the  free  chlorine,  and  similarly  the 
percentage  of  the  combined  acid  with  that  of  the 
chlorine  in  combination  with  organic  bodies. 

The  free  chlorine  determined  in  this  way  consists 
of  hydrochloric  acid  and  of  any  chloride  of  ammonia 
present ;  and  the  combined,  of  hydrochloric  acid  and 
other  chlorine  compounds  with  organic  bases. 

Some  difficulty  may  be  experienced  in  determining 
the  exact  point  at  which  the  end  reaction  occurs  in 
the  estimation  of  the  acidity  after  evaporation.  Often 
the  residue  left  is  highly  coloured.  The  best  way 
to  proceed  is  to  divide  the  solution  obtained,  after 
dissolving  the  residue  in  distilled  water,  into  two  equal 
parts,  and  to  use  one  without  the  addition  of  soda  as 
a  means  of  comparison  with  the  other,  to  which 
soda  has  been  added,  so  that  the  point  at  which  the 
phenol-phthalein,  becoming  pink,  affects  the  tint  of 
the  solution,  may  easily  be  determined. 


82  author's  clinical  method 


Example. 

Stomach  Contents  removed  from  a  case  of  nervous  dyspepsia 
with  delayed  digestion,  heartburn,  and  intestinal  symptoms. 

Removed  two  and  a  quarter  hours  after  breakfast  of  minced 
meat,  toast,  and  water. 

Fluid  turbid  ;  meat  partly  digested  ;  smell  sour  ;  no  scum. 

1.  Total  Acidity. 

N 
10  c.  c.  titrated  with  —  soda  solution  and  phenol-phthalein. 

10  r  r 

7-8  c.  c.  used  (7-8xo-oo365)  =  o-02847  =  o-2847  percent., 
or  78. 

2.  Acidity  after  Evaporation. 

10  c.  c,  7" 3  c.  c.  ^  soda  used. 

7"3  X  0'00365  =  0'026645  grm.  HCl  =  ov2664  per  cent.,  or  73. 
Faint  trace  of  violet  colour  in  contents  of  capsule  after 
drying. 

3 .  Volatile  A  cidily  •. 

0"5    c.  c.    (i  —  2)  =  (o-5  xo"00365)    o'ooi825    grm.    HC1  = 

0'0i825  per  cent.,  or  5. 
Tested    with   vanillin-phloroglucin,  a    faint    red    colour 

developed  on  drying. 
Tested  with  Uffelmann's  reagent,  the  presence  of  lactic 
acid  was  shown. 
Such  forms  the  ordinary  clinical  method,  but  for  the  purposes 
of  illustration  the  further  processes  available  were  carried  out. 

4.  Total  Chlorine. 

The  10  c.  c.  of  capsule  i,  after  neutralisation,  and  after  the 
addition  of  a  pinch  of  sodium  carbonate  to  ensure  excess 
of  the  alkali,  were  dried,  and  ashed  at  a  dull  red  heat. 
The  resulting  ash  was  dissolved  in  water,  filtered,  the 
filter  paper  washed  with  distilled  water,  and  the  filtrate 
tested  as  in  Hayem  and  Winter's  method,  after  neutral- 
ising with  nitric  acid. 

In  this  instance  a  solution  of  silver  nitrate  was  used, 
9*5  c.  c.  of  which  corresponded  to  10  c.  c.  of  deci-normal 
hydrochloric  acid  solution,  or  to  C"0365  grm.  of  HCl. 


AUTHOR  S    CLINICAL    METHOD 


8-3  c.  c.  of  the  silver  solution  was  added  before  the  potas- 

1  *     1  *    I         ^  J  0-0365  x8-3 

Slum  chromate  befran  to  be  acted  on,  or  — ^ — = ■   = 

9-5 
0*03 188  grm.  HCl  in  10  c.  c,  or  0'3i88  per  cent. 

5.  Non-volatile  Chlorine. 

The  contents  of  No.  2  were  similarly  treated,  after  testing 
the  acidity. 

8'i  c.  c.  of  the  silver  solution  were  required,  or 


=  o'03ii2  grm.  HCl  in  10  c.  c,  or  o'3ii2  per  cent. 

6.  Volatile  Chlorine. 

The  result  of  No.  5  subtracted  from  that  of  No.  4  gives 
only  0-2  c.  c.  of  the  silver  solution  as  the  equivalent  of 
the  volatile  chlorine,  and  this  is  equal  to  0-0076  per 
cent,  of  free  hydrochloric  acid. 

7.  Inorganic  Chlorine. 

Other  10  c.  c.  were  dried  without  addition  in  a  capsule, 
incinerated  at  a  low  red  heat  for  a  considerable  time, 
and  the  ash  treated  as  before. 

4*4  c.  c.  of  the  silver  solution  sufficed  to  combine  with  all 

grm.  HCl,    or 


the  chlorine,  or 

0-0365  X 
9-5 

-43  =.0-01 

0-1689  psi"  cent. 

suit.— 
Total  acidity. 

Re. 
I. 

0-2847 

per  cent. 

2. 

Non-volatile  acidity. 

0-2664 

,, 

3- 

Volatile  acidity, . 

0-01S25 

,, 

4- 

Total  chlorine,  . 

0-3188 

,, 

5- 

Non-volatile  chlorine, 

0-3112 

,, 

6. 

Volatile  chlorine, 

0-0076 

,, 

1  • 

Inorganic  chlorine,     . 

0-1689 

,, 

8. 

Organic     non-volatile 
chlorine,  or  chlorine 
combined  with  pro- 

i 

teids(5-7)    . 

0-1423 

9- 

Total    chlorine    apart 

i 

1 

from  inorganic  chlo- 

rides (6  +  8)    . 

0-1499 

< 

(4-5)   ■ 

Chlorine  com- 
bined with  pro- 
teids. 

'I'otal  chlorine,  as 
HCl,  free  and 
combined. 


84  author's  clinical  method 

^,      ,       .  ,.  ,  (  Total  acidity  due 

10.  iotal  acidity  not  due  \      ^  ■  '     -j^ 

,  ,     .  -^    ,         .  „  -<       to  organic  acids 

to  chlorine  (1-9)    =0-1348  per  cent,  "j      ^^^   ^^  ^^j^^_ 

11.  Non-volatile       acidity  .^^^^.^     ^^.^     ^^^ 

not  due  to  chlorine  I  -j      1^ 

'      acid  salts. 
(2-8)     .         .         =0-1241 

12.  Volatile     acidity     not  (  Volatile      organic 

due     to      chlorine  <      acid  =  acetic 

(3-6)     .         .        =0-01065        »  i      ^cid. 

The  figures  obtained  show  the  presence  of  a  very  small  quan- 
tit)'  of  free  hydrochloric  acid,  not  sufficient  to  check  the  lactic 
acid  fermentation,  a  moderate  amount  of  combined  hydrochloric 
acid,  a  comparatively  large  quantity  of  lactic  acid,  and  a  trace  of 
a  volatile  organic  acid,  probably  acetic. 

4.  Quantitative  Tests  for  the  Organic  Acids, 

If  the  organic  acids  be  volatile  the  amount  present 
may  be  estimated  by  titration  of  the  distillate  of  a 
known  quantity  of  the  contents. 

If  partly  volatile,  z.e.,  acetic  and  butyric  acids, 
and  partly  non-volatile,  z'.s.,  lactic  acid,  titration  of 
the  distillate  and  of  a  watery  solution  of  the  residue 
of  an  ether  extract  of  the  fluid  remaining  in  the 
retort  will  give  the  total  amount  of  organic  acids 
present  fairly  accurately  (zn'de  p.  42.) 

5.  Other  Methods. 

Contejean's  Method. — Contejean*  suggests  the  use 
of  hydrocarbonate  of  cobalt,  added  in  excess  to  the 
stomach  contents,  as  a  qualitative  test  for  the  acids 
in  the  gastric  contents. 

The  mixture   is  shaken  or  stirred  frequently,  and 

*  Journ.  d.  /.  Phys,  et.  d.  I'Anat.,  No,  i,  1893. 


OTHER    -METHODS  85 

becomes  pink  in  the  course  of  a  few  hours  if  some 
oxide  of  cobalt  be  formed  and  dissolved,  while  the 
residue  after  filtering  and  drying  is  blue.  If  absolute 
alcohol  be  now  added,  any  chloride  of  cobalt 
present  is  dissolved  by  it,  and  can  thus  be  separated 
from  the  lactate,  which  is  insoluble  in  alcohol.  The 
chloride  of  cobalt  solution  is  of  a  pink  colour  when 
cold,  turning  to  blue  on  heating.  On  evaporation 
rectangular  crystals  of  this  salt  may  be  obtained,  and 
serve  as  irrefragable  evidence  of  the  presence  of 
hydrochloric  acid.  To  ascertain  the  positive  presence 
of  lactic  acid,  he  advises  that  the  stomach  contents 
should  be  shaken  up  several  times  with  ether,  the 
ether  removed,  evaporated,  and  the  residue  dissolved 
in  distilled  water,  to  which  zinc  oxide  has  been  added. 
This  mixture  has  to  be  kept  for  some  time  at  a  mild 
heat,  when,  if  lactic  acid  be  present,  crystals  of  lactate 
of  zinc  may  be  found  under  the  microscope  on  eva- 
poration of  the  solution. 

Hoffmann's  Method.  —  Hoffmann*  has  suggested 
that  the  amount  of  free  hydrochloric  acid  in  the 
gastric  contents  may  be  estimated  by  the  degree  of 
inversion  of  cane  sugar,  measured  by  the  polarimeter, 
brought  about  by  its  action.  Or  by  the  splitting  of 
methyl-acetate  into  methyl-alcohol  and  acetic  acid,  by 
the  action  of  free  hydrochloric  acid,  and  titration  of 
the  acetic  acid  formed. 

Brauns  Method.j — The  total  acidity  of  10  c.c,  or 
any  other  fixed  quantity  of  the  stomach  contents, 
is  determined  in  the  ordinary  way,  and  then  i  c.c. 
more  of  the  deci-normal  solution  of  soda  is  added. 

*   Centralblatt f.  klin.  Med.,  No.  16,  1889. 

f  See  Leube,  Specielle  Diagnostik,  etc.,  p.  234,  1889. 


86  MIERZYN ski's    METHOD 

Dry  and  incinerate.  Then  as  much  of  a  deci-normal 
solution  of  sulphuric  acid  is  added  as  is  required  to 
neutralise  the'  soda  used.  Warm  the  mixture  to 
get  rid  of  carbonic  acid,  and  titrate  with  deci-normal 
soda  again.  The  quantity  of  the  solution  used  repre- 
sents the  amount  of  hydrochloric  acid  originally 
present. 

Mierzynski's  Gas  Volumetric  Method*  - —  Five  to 
15  c.  c.  of  the  stomach  contents,  after  filtration, 
are  mixed  with  an  excess  of  carbonate  of  barium  in 
a  porcelain  crucible,  dried,  and  incinerated.  The  ash 
is  dissolved  in  boiling  water,  and  filtered.  It  often 
contains,  in  addition  to  the  soluble  chloride  of  barium, 
some  of  the  hydrate,  owing  to  reduction  of  the  car- 
bonate during  incineration.  If  this  is  the  case,  a  drop 
of  phenol-phthalein  will  colour  the  solution  pink.  To 
get  rid  of  the  hydrate  all  that  is  necessary  is  to  blow 
air  through  a  glass  tube  until  the  pink  colour  dis- 
appears, and  filter  once  again.  To  the  filtrate 
ammonium  chromate  is  added  in  slight  excess,  the 
solution  heated,  and  the  precipitate  which  forms 
caught  on  a  filter  paper.  This  is  then  washed  with 
very  dilute  hot  ammonia  to  remove  any  remaining 
chromate.  The  lower  end  of  the  filter  is  now  pierced, 
and  the  precipitate  washed  through  with  i  in  20 
hydrochloric  acid  solution  in  excess,  to  which  10  c.  c. 
dilute  sulphuric  acid  is  finally  added.  The  solution  is 
now  placed  in  a  ureameter,  5  to  10  c.  c.  of  a  2  per 
cent  to  2'5  per  cent,  peroxide  of  hydrogen  solution 
mixed  with  it,  shaken  for  half  a  minute,  and  the 
quantity  of  oxygen  evolved  calculated  from  the 
height  of  the  water  in  the  tube  of  the  apparatus. 

*  Ceniralblatt f.  vinere  Med.,  No.  15,  s.  1073,  1894. 


TABLE    OF    METHODS  Sy 

2HCH-BaC03=CO,  +  H<,0  +  BaCl, 
BaCl2  +  (NH;)2Cr04  =  2NH,Cl  +  BaCr04 
2BaCrO,+  5H20  +  5H2S04=2BaSO,+  Cr2(SOJ3 
+  ioH,0  +  80 
Therefore,  2HCl  =  BaCl2  =  BaCr04  =  40. 

The  result  is  then  corrected  for  temperature  and 
pressure,  and  the  number  of  c.  c.  multiplied  by  half 
the  molecular  weight  of  HCl. 

For  example — -lo  c.  c.  of  stomach  contents  gave 
22"4  c.  c.  of  oxygen  at  742  mm.  pressure,  and  16°  C. 
To  correct  for  temperature  and  pressure  22*4  must  be 
multiplied  by  0-o8io6  (from  Baumann's  Tables),  and 
by  i8'i85,  or  half  the  molecular  weight  of  HCl.  This 
gives  33'Oi8  m.  grm.  in  10  c. c,  or  3-3  per  thousand. 

Table  of  the  Methods  used  for  the  Detection 
and  Estimation  of  the  Acids  present  in  the 
Stomach  Contents. 

I .   Qualitative. 

a.  Simple  acidity  only.     Litmus. 

b.  Form  of  acid  present. 

1.  Free  hydrochloric  acid. 

a.  Vanillin-phloroglucin. 

b.  Resorcin. 

c.  Sulphocyanide      of      potassium      and 

acetate  of  iron. 

d.  Dimethyl-amido-azo-benzol. 

2.  Free  acids  of  any  kind. 

a.  Congo  red.  '    . 

b.  Tropseolin  00  {L Orange  Poirier). 

c.  Benzo-purpurin. 


88  TABLE    OF    METHODS 

d.  Methyl-violet 

e.  Emerald  green  (Vert  Brilliant). 

f.  Fuchsin. 

Z.  Leo's  method. 


0 


Organic  acids. 

a.  Carbolic  acid  and  perchloride   of  iron. 

b.  Dilute  perchloride  of  iron. 

c.  Co-efficient  de  partage. 

d.  Alcohol     and      sulphuric     acid,     with 

formation  of  ethers. 


Quantitative. 

a.  Total     acidit}',     titration     with     deci-normal 

sodium    hydrate,   and    phenol-phthalein   or 
litmus. 

b.  Acids  forming  the  total  acidity. 

1.  Hydrochloric  acid  only. 

a.  Free  HCl  only.     ]\Iintz's  method. 

b.  Hydrochloric  acid,  free  and  combined 

with  proteids.     Sjoqvist's  method. 

2.  All  the  acids  present. 

a.  Cahn  and  Von  IMering. 

b.  Mintz-Boas 

c.  Hayem  and  Winter. 

d.  Toepfer. 

e.  Li.ittke  and  Martius. 

/    ^Modified  Hayem  and  Winter. 

3.  Organic  acids  alone. 

1.  Distillation  and  titration  of  distillate. 

2.  Titration  before  and  after  ether. 


TABLE    OF    METHODS  89 

3.   Otha^  less  knoivn  inetJiods* 

1.  Contejean's  methods.     Qualitative. 

2.  Hoffmann's     method.      Quantitative    for 

free  hydrochloric  acid. 

3.  Braun's   method.     Quantitative  for   total 

hydrochloric  acid. 

4.  Mierzynski's    gas  volumetric  method,  for 

total  hydrochloric  acid. 

*   See  Appe7tdix^  p.  161. 


CHAPTER   VL 

GENERAL    CONSIDERATION    OF  THE   DIFFERENT 
CHEMICAL  METHODS  DESCRIBED. 

The  various  methods  for  the  estimation  of  the 
hydrochloric  acid  and  fatty  acids  in  the  stomach 
contents,  which  have  been  described  in  the  preceding 
chapters,  may  be  divided  into  two  classes.  The  first 
class  contains  those  methods  in  which  the  proportion 
of  hydrochloric  acid  is  determined  irrespective  of  the 
chemical  state  in  which  it  is  present ;  the  second,  those 
in  which  the  amount  of  acid,  both  in  a  free  state  and 
combined  with  proteids,  is  determined. 

The  first  class  consists  of  the  methods  of — 

1st.     Cahn  and  von  Mering. 

2nd.  Sjoqvist. 

^7-d.   Leo. 

4///.    Martius  and  Liittke. 

The  differentiation  of  the  hydrochloric  acid  present 
into  that  which  is  free  and  that  which  is  combined 
with  proteid  bodies,  is  carried  out  by  the  processes 
of— 

1st.     Mintz. 

2;?^.  Mintz  and  Boas. 

2,rd.   Toepfer. 

4///.    Hayem  and  Winter  ;  and 

St/i.    Of  the  Author. 


CONSIDERATION    OF    METHODS  QI 

If  one  wishes  to  ascertain  the  total  quantity  of 
chlorine  present  as  hydrochloric  acid  in  a  sample  of 
stomach  contents,  no  process  can  be  more  accurate 
than  that  of  Sjoqvist.  If  one  desires  to  determine 
the  quantity  of  chlorine  combined  Avith  inorganic 
salts,  and  in  the  form  of  hydrochloric  acid,  free  and 
combined  together,  Martins  and  Liittke's  method 
affords  good  results.  The  method  of  Cahn  and  von 
Mering  may  be  at  once  dismissed,  because,  as  has 
already  been  noted,  it  is  both  costly  and  difficult. 
The  method  of  Sjoqvist  requires  much  skill  in 
chemical  analysis,  while  that  of  Martins  and  Liittke, 
although  accurate,  does  not  yield  all  the  information 
which  may  be  of  use.  On  the  other  hand,  the  simple 
method  of  Mintz  and  Boas  quickly  indicates  the 
proportion  of  free  hydrochloric  acid  in  the  contents, 
accurately  if  it  is  the  only  acid  present,  slightly  in 
excess  of  its  real  value  if  organic  acids  are  also 
present.  The  method  of  Hayem  and  Winter  affords 
much  more  information,  and  appears  to  be  fairly 
accurate.  By  it  the  total  acidity,  the  free  hydro- 
chloric acid,  the  hydrochloric  acid  combined  with 
proteids,  and  the  inorganic  chlorides,  are  all  deter- 
mined. It  is,  however,  somewhat  tedious  to  carry  out, 
and  requires  considerable  chemical  skill  in  the 
estimation  of  the  chlorine  present.  Toepfer's  method 
is  easy  and  does  not  take  up  much  time,  nor  does  it 
require  any  costly  apparatus.  It  may  be  warmly 
recommended  for  the  ordinary  clinical  examination 
of  the  stomach  contents.  The  figures  obtained  are 
not,  in  all  probability,  absolutely  accurate,  but  for 
clinical  work  the  accuracy  of  the  analytical  chemist  is 
not  required.     What  we  wish  to  know  is  how  acid  the 


92  SIGNIFICANCE    OF    ACIDITIES 

stomach  contents  in  any  given  case  are,  and  what  this 
acidity  is  made  up  of.  The  modification  of  Hayem 
and  Winter's  method,  used  for  some  years  past  by  the 
author,  is  likewise  attended  with  the  possibiHty  of 
some  error  ;  the  process,  however,  is  simple  and  easy, 
and  in  his  hands  has  afforded  so  much  information 
with  little  trouble,  and  has  been  of  so  much  use  in  the 
diagnosis  and  treatment  of  cases  of  dyspepsia  of  all 
kinds,  that  he  is  disposed  to  recommend  it  for 
employment  in  clinical  work.  By  it  we  obtain  infor- 
mation as  to  the  total  acidity  and  as  to  the  acidity 
left  after  evaporation  ;  while  coupled  with  the  ordinary 
quantitative  tests  for  the  presence  of  free  mineral  acid 
or  of  the  fatty  acids,  the  process  affords  all  the 
information  required  to  diagnose  the  faulty  chemistry 
which  may  underlie  gastric  affections. 

After  the  performance  of  many  of  the  processes 
detailed  above,  in  which  the  principal  point  aimed  at 
is  the  estimation  of  the  chlorine  present,  the  presence 
of  the  fatty  acids,  and,  if  required,  the  amount  of 
these  acids  in  the  contents,  may  be  determined  by  the 
use  of  the  various  tests  described  in  Chapter  IV. 

The  Significance  of  the  different  Acidities 
obtained  in  the  Stomach  Contents. 

In  an  artificial  digestion  experiment,  in  which 
nothing  but  hydrochloric  acid,  pepsin,  and  proteid 
bodies  are  present,  until  the  acid  has  been  added  up 
to  a  certain  proportion,  namely,  to  about  7  per  cent, 
of  the  proteids,  no  free  hydrochloric  acid  appears  in 
the  fluid.  It  has  all  combined  with  the  proteids  present. 
It    gives    no    coloration    with    Giinzbure's    or    with 


SIGNIFICANCE    OF    ACIDITIES  93 

Mohr's  reagent,  but  still  retains  the  same  acid  value 
in  titration  which  it  possessed  before  combination. 
That  is  to  say,  that  if  10  c.  c.  of  a  deci-normal  solu- 
tion of  hydrochloric  acid  be  added  to  a  solution  of 
any  proteid  in  which  the  proteid  is  in  excess,  no  free 
acid  can  be  detected,  but  the  mixture,  provided  it  is 
neutral  before  the  addition  of  the  acid,  is  exactly 
neutralised  again  by  the  addition  of  10  c.  c.  of  deci- 
normal  soda.  This  combination  of  hydrochloric  acid 
with  proteid  bodies  represents  the  first  stage  in  their 
digestion,  and  therefore  the  amount  of  the  acid  in 
combination  may  be  regarded  as  an  index  of  work 
already  done.  Further,  if  in  our  artificial  digestion 
experiment  more  acid  be  added,  none  of  it  will  be 
found  to  be  present  in  a  free  state  until  from  7 
to  9  per  cent,  of  the  acid,  when  compared  with  the 
proteid,  is  contained  in  the  fluid.  During  the  decom- 
position of  the  native  proteid  molecules,  however, 
simpler  proteid  bodies  are  formed  which  have  a  greater 
afiinity  for  the  acid  ;  and  a  solution  of  albumin,  which 
contains  at  the  commencement  of  digestion  a  small 
quantity  of  free  hydrochloric  acid,  may,  as  digestion 
proceeds,  exhibit  no  trace  of  it ;  that  is  to  say,  the 
lower  proteids  resulting  from  the  digestive  act  are  able 
to  combine  with  more  of  the  acid  than  the  native 
albumin  from  which  they  are  derived.  Thus,  the 
albumoses  appear  to  be  capable  of  combining  with 
from  II  to  15  per  cent,  of  hydrochloric  acid,  and  pure 
peptone  with  about  19  to  20  per  cent.  If  these  facts 
be  remembered,  the  amount  of  combined  hydrochloric 
acid  obtained  by  any  of  the  methods  described  above, 
will  indicate  the  ability  of  the  gastric  glands  to  secrete 
sufficient  hydrochloric  acid  not  only  to  act  upon  and 


94  SIGNIFICANCE    OF    ACIDITIES 

combine  with  all  the  proteids  of  the  food,  but  to 
provide  the  slight  excess  of  free  acid  which  enables  the 
process  of  decomposition  of  the  proteid  bodies  to  go 
on  to  its  natural  termination. 

The  presence  of  free  hydrochloric  acid  in  the 
contents,  remembering  what  we  have  just  said,  in- 
dicates a  power  of  further  digestion  on  the  part  of 
the  gastric  juice.  Its  absence  may  denote  diminished 
activity  of  the  gastric  glands,  unless  the  contents 
have  been  removed  shortly  after  a  heavy  proteid 
meal.  A  low  total  acidity  after  food  composed 
largely  of  carbohydrates,  does  not  invariably  indicate 
diminished  digestive  powers.  The  gastric  glands 
appear  to  be  able  to  regulate  the  amount  of  acid 
secreted,  not  so  much  in  relation  to  the  combined 
acid  present,  but  in  connection  with  the  proportion  of 
free  hydrochloric  acid  in  the  contents.  So  we  may 
say  that  a  low  acidity  with  little  combined  acid  and 
the  normal  amount  of  free  mineral  acid  is  by  no 
means  abnorm.al,  if  the  food  has  contained  a  small 
proportion  of  albuminous  material ;  on  the  other 
hand,  a  very  high  acidity,  even  0"4  to  0*45  per  cent. 
(HCl)  with  or  without  free  hydrochloric  acid,  does  not 
necessarily  indicate  hyperacidity  if  the  contents  have 
been  remioved  after  a  food  chiefly  consisting  of 
proteids.  But  if  with  a  low  acidity  no  free  hydro- 
chloric acid  can  be  detected  after  a  meal  of  carbo- 
hydrates, or  if  the  acidity  some  time  after  proteid  food 
is  normal  but  does  not  similarly  contain  any  free  hydro- 
chloric acid,  we  are  justified  in  diagnosing  a  diminished 
secretion  of  acid  in  the  gastric  juice.  Again,  if 
in  the  first  instance,  after  carbohydrates,  there  is 
a  normal  total  acidity  almost  entirely  composed  of 


SIGNIFICANCE    OF    ACIDITIES  95 

free  mineral  acid ;  or  in  the  second,  that  is,  after 
proteid  food,  the  total  acidity  be  very  high  with  the 
same  proportion  of  combined  acid  as  should  normally 
be  present  but  with  a  greater  quantity  of  free  acid, 
we  may  look  upon  the  patient  as  suffering  from 
hyperchlorhydria, — in  other  words,  too  great  a  secre- 
tion of  hydrochloric  acid  from  the  gastric  glands. 


CHAPTER   VII. 

THE  ACTIVITY   OF   THE   GASTRIC   JUICE. 

Tests  for  the  Activity  of  ihe  Gastric  Juice — Egg  Albumin — Giinzburg's 
and  Sahli's  Iodide  of  Potassium  Test — Oppler's  Test — Rennet — 
The  Identification  and  Estimation  of  the  Forms  of  Proteid  present 
— Sugar  and  Starch — Saliva — Toxines. 

Tests  for  the  Activity  of  the  Gastric  Juice. 

To  obtain  an  indication  of  the  activity  of  the  gastric 
juice,  the  white  of  one  or  two  eggs,  apart  from  the 
yolk,  are  mixed  with  4  oz.  of  water,  and  the  solution 
heated  to  the  boiling  point,  with  constant  stirring. 
The  albumin  is,  in  this  way,  coagulated  in  fine  par- 
ticles. After  cooling,  it  is  given  to  the  patient,  and 
b}-  means  of  the  stomach-tube  removed  from  the 
stomach  in  half  an  hour  to  three-quarters  of  an  hour 
afterwards,  after  the  addition  of  4  or  5  oz.  of  water. 
The  stomach  should  be  empty  before  the  white  of  eg<^ 
mixture  is  given,  or,  if  it  is  not  empty,  should  be 
washed  out  beforehand.  Examination  of  the  fluid 
removed  will  show  whether  the  digestion  of  the 
albumin  has  proceeded  to  a  termination  or  not.  The 
egg-albumin,  as  yet  unaltered,  can  be  separated  by 
boiling  the  fluid,  with  the  addition,  if  necessary,  of 
acetic  acid,  and  filtering.  The  acid  albumin  is  re- 
moved   after   precipitation   with   an    alkali    close   to 


■  ACTIVITY    OF    GASTRIC    JUICE  97 

the  neutral  point.  The  presence  of  albumoses  or 
peptone  in  the  filtrate  can  then  be  ascertained  by 
means  of  the  biuret  reaction.  The  acidity  and  the 
constituents  of  the  acidity  can  be  readily  determined 
by  any  of  the  methods  described  above,  and  the 
presence  of  pepsin  investigated  by  an  artificial  diges- 
tion experiment.  The  degree  of  acidity  of  the  fluid 
obtained  in  this  way  will  be  equal  to  one-half  only  of 
the  true  acidity  of  the  stomach  contents,  since  an 
equal  part  of  water  has  been  added  to  the  contents 
before  they  are  withdrawn. 

This  method  is  a  very  accurate  means  for  determin- 
ing the  activity  of  the  gastric  secretion  in  health  or 
disease.  Egg-albumin  is  readily  digested  in  the 
stomach,  and  does  not,  during  its  digestion,  give  rise 
to  any  organic  acids.  If  a  considerable  proportion  of 
the  albumin  given  has  been  altered,  and  is  no  longer 
in  the  coagulated  form  at  the  end  of  one-half  to  an 
hour,  the  gastric  digestion  may  be  regarded  as  normal. 
If,  however,  very  little  of  the  albumin  has  been 
rendered  soluble,  that  is  to  say,  has  been  converted 
into  lower  proteid  forms,  and  the  contents  removed 
are  only  slightly  acid,  we  have  good  evidence  of  a 
defective  secretion  of  gastric  juice. 

Gunzburg  and  Sahli  *  have  proposed  another 
method  to  ascertain  the  rapidity  of  the  gastric  diges- 
tion of  albumin  and  fibrin.  A  small  quantity  of 
iodide  of  potassium,  O'l  to  0"2  grm.  (gr.  iss.  to  iij.)  is 
enclosed  in  an  envelope  of  fibrin  or  in  a  thin  gum  packet 
fastened  with  a  string  of  fibrin.  The  salt  may  also  be 
given,  placed  in  a  short   piece  of  thin    indiarubber 

*  Deutsch.  med.  Wochenschr.,  1889,  No.  41,  and  Correspondenzblatt 
der  Schweizer  Ae7'zte,  1889,  p.  402. 

G 


98  ACTIVITY    OF    GASTRIC    JUICE 

tubing,  the  ends  of  which  are  firmly  closed  with  plugs 
of  fibrin.  The  iodide  can  only  be  absorbed  by  the 
mucous  membrane  of  the  stomach  when  the  envelope 
of  fibrin  has  been  digested.  The  length  of  time  re- 
quired for  the  appearance  of  the  salt  in  the  saliva 
(see  page  12)  is  regarded  by  them  as  an  indication  of 
the  rapidity  of  gastric  digestion.  The  time  taken  for 
the  absorption  of  iodide  of  potassium  is  very  variable, 
and  the  rapidity  with  which  the  fibrin  enveloping  the 
salt  is  dissolved  bears  no  direct  relation,  in  many  cases, 
to  the  presence  of  free  hydrochloric  acid  in  the  con- 
tents, as  it  is  often  digested  as  rapidly  in  the  absence 
as  in  the  presence  of  this  acid  in  a  free  state.  The 
time  taken,  also,  for  its  digestion  will  vary  with  the 
contents  present  along  with  it  in  the  stomach. 

A  simple  way  of  determining  the  presence  or 
absence  of  pepsin  and  free  hydrochloric  acid  in  the 
stomach  contents  may  be  performed  in  the  following 
manner : — Small  discs  of  coagulated  white  of  egg  may 
be  cut  by  means  of  a  double-bladed  knife,  and  the 
sections  thus  obtained  punched  with  a  cork-borer  or 
other  similar  instrument,  so  as  to  produce  discs  of 
albumin  equal  in  size  and  thickness.  These  discs 
may  be  preserved  in  glycerine  till  required.  An  equal 
quantity  of  the  filtered  stomach  contents  is  then 
placed  in  four  test-tubes  and  one  or  two  discs  of  the 
albumin  placed  in  each.  To  the  first  nothing  further 
is  added ;  to  the  second,  two  drops  of  the  dilute 
hydrochloric  acid  of  the  Pharmacopoeia  to  each  5  c.  c. 
of  the  stomach  contents ;  to  the  third,  0'2  to  0"5  grm. 
(gr.  iij.  to  vij.)  of  pure  pepsin  is  added  ;  and  to  the 
fourth,  both  the  acid  and  the  ferment.  The  test-tubes 
are  then  placed  in  an  incubator,  the  temperature  of 


ACTIVITY    OF    GASTRIC    JUICE  99 

which  is  kept  at  about  100''  F.,  or  in  any  other  warm 
and  suitable  place.  The  rapidity  of  the  solution  of 
the  albumin  discs  informs  us  whether  digestion  can 
take  place  without  the  addition  of  hydrochloric  acid 
or  pepsin,  or  whether  one  of  these  bodies  or  both  are 
necessary.  The  actual  digestive  power  of  the  contents 
upon  albumin  may  be  ascertained  by  adding  a  known 
quantity  of  pure  egg-albumin,  coagulated  or  un- 
coagulated,  to  10  c.  c.  of  the  stomach  contents,  and  by 
weighing  the  albumin  which  can  still  be  coagulated 
by  the  aid  of  heat  on  a  weighed  filter  paper.  The 
percentage  of  loss  will  give  the  digestive  activity  of 
the  specimen  examined. 

It  should  be  remembered,  with  regard  to  these 
tests,  that  a  perfectly  normal  and  active  sample  of 
the  stomach  contents  may  exert  no  digestive  action 
on  albumin,  unless  free  hydrochloric  acid  be  added, 
owing  to  the  fact  that  all  the  hydrochloric  acid 
present  has  combined  with  proteid  bodies  originally 
present.  In  such  a  case  the  contents  will  have  prob- 
ably been  removed  before  the  height  of  digestion. 

Oppler*  has  lately  described  a  nev/  method  of  esti- 
mating the  activity  of  pepsin.  An  hour  after  a  test- 
breakfast  the  contents  of  the  stomach  are  expressed, 
and  the  organ  washed  out  with  a  small  quantity  of 
distilled  water.  The  contents  and  washings  are  then 
diluted  to  I  or  2  litres,  as  may  be,  with  distilled  water 
and  dilute  hydrochloric  acid  added  until  the  total 
acidity  stands  at  77  =  0'28i  per  cent. 

A  2"i  per  cent,  solution  of  egg-albumin  is  prepared, 
and  the  nitrogen  of  it  estimated  by  Kjeldahl's  method. 
Twenty  c.  c.  of  the  albumin  solution  are  then  added  to 

*  Cenlralblatt f.  hinere  Med.,  February  I,  1896. 


TOO  RENNET 

50  c.c.  of  the  diluted  stomach  contents,  and  the  mix- 
ture digested  at  375°  (for  three  hours).  After  coagu- 
lation and  precipitation  of  the  albumin  and  acid- 
albumin  remaining,  and  removal  of  them  by  filtration, 
the  nitrogen  of  the  proteids  in  the  filtrate  is  estimated 
and  the  percentage  of  albumin  acted  on  calculated. 

He  finds  that  the  formation  of  pepsin  is  diminished 
in  chronic  gastritis,  carcinoma  of  the  stomach,  especi- 
ally if  situated  on  the  body.  When  the  pylorus  is  the 
seat  of  the  disease  th^  ferment  persists  longer  than  the 
hydrochloric  acid,  but  gradually  diminishes.  In 
atony  and  dilatation  pepsin  is  only  secreted  in  less 
quantity  if  catarrh  be  present  with  diminished  acid. 
Pepsin  is  increased  in  gastric  ulcer,  acid  dyspepsia, 
chronic  hypersecretion  {Reichniaini's  Magensaftjluss), 
and  sometimes  in  chlorosis.  Nervous  dyspepsias  and 
secondary  affections  of  the  stomach  with  lessened 
acidity  are  accompanied  by  diminished  pepsin  for- 
mation. 

The  activity  of  pepsin  secretion  runs  parallel  with 
that  of  the  hydrochloric  acid,  but  the  correspondence 
is  not  always  complete.  • 

Rennet. 

To  ascertain  whether  the  milk-curdling  ferment  is 
present,  a  small  quantity,  say  10  c.  c,  of  boiled  milk  of 
neutral  reaction,  is  mixed  with  an  equal  amount  of 
neutralised  and  filtered  stomach  contents.  If  the 
mixture  be  kept  at  a  temperature  of  100°  F.  for  a 
short  time,  the  milk  generally  coagulates  in  about  ten 
to  fifteen  minutes.     Leo  *  adds  only  two  to  five  drops 

'^  Diagnoztik,  1 890,  p.  1 19. 


TESTS    P-QR    PROTEIDS  lOI 

of  the  stomach  contents  to  lo  c.  c.  of  raw  milk  without 
neutraHsing  the  former,  on  account  of  the  relatively 
small  quantity  of  it  added  to  the  milk.  Raw 
milk  is  recommended  by  him  because  it  coagulates 
ten  times  more  rapidly  than  milk  which  has  been 
boiled.  Neutralisation  of  the  stomach  contents  is 
rendered  necessary  in  the  first  method  by  the  fact 
that,  if  it  be  even  moderately  acid,  the  milk  coagulates 
in  the  absence  of  rennet,  the  coagulation  in  such  a 
case  being  flaky  or  lumpy,  unlike  the  characteristic 
cake  or  layer  of  casein  floating  in  the  whey  when 
formed  by  the  action  of  rennet. 

Tests  for  tlie  Identification  and  Estimation  of  the 
Proteids  Present  in  the  Gastric  Contents. 

In  some  cases  it  may  be  desired  to  ascertain 
whether  the  products  of  the  peptic  digestion  of  the 
native  proteids  of  the  food  are  present  or  not,  or, 
again,  to  estimate  the  quantities  of  each  form  con- 
tained in  solution.  Before  applying  any  of  the 
requisite  tests  the  contents  must  be  thoroughly 
filtered.  If  there  be  much  mucus  present,  filtration 
through  paper  is  a  slow  and  tedious  business.  It  is 
best  to  first  strain  them  through  well-washed  muslin, 
and  then  filter  through  thin  white  filter  paper.  If 
speedy  filtration  be  desired,  an  exhaust  pump  may 
prove  of  advantage. 

A  certain  quantity  of  the  filtrate,  say  lO  c.  c,  is 
measured  out  by  means  of  a  pipette,  and  deci-normal 
soda  solution  cautiously  added.  If  any  acid  albumin 
be  present,  the  fluid  gradually  becomes  opalescent 
shortly  before  neutralisation,  and  the  addition  of  one 


102  TESTS    FOR    PROTEIDS 

or  two  drops  more  of  the  soda  brings  down  a  floccu- 
lent  precipitate  of  this  proteid.  The  precipitate  is 
filtered  off,  on  a  weighed  filter  paper  if  desired,  and 
washed  with  distilled  water.  The  filtrate  is  still 
slightly  acid  in  reaction,  but  no  further  precipitate 
comes  down  when  a  drop  or  two  of  the  soda  solution 
is  added  to  it. 

The  filtrate  is  now  boiled,  and  at  the  boiling  point 
made  slightly  acid  with  acetic  acid.  All  the  coagul- 
able  proteids  fall  and  may  be  filtered  off,  and  the 
precipitate  washed  with  boiling  distilled  water. 

The  proteids  remaining  in  this  second  filtrate  con- 
sist of  albumoses  and  peptone. 

The  biuret  test  may  be  applied  to  a  small  portion 
of  the  filtrate  for  the  purpose  of  detecting  the  presence 
of  these  bodies  in  it.  To  this  end  a  drop  of  i  per  cent, 
sulphate  of  copper  solution  is  added  to  a  portion  in  a 
test-tube,  giving  it  a  slight  greenish-blue  tinge,  which 
changes  to  a  more  or  less  bright  pink  on  the  addition 
of  a  small  amount  of  liquor  potass^,  or  of  a  40  per 
cent  solution  of  caustic  potash,  indicating  the  presence 
of  albumose  or  peptone.  Fehling's  solution  may  be 
similarly  used,  a  small  drop  being  added  by  means  of 
a  glass  rod,  and  a  little  potash  if  needful.  Fehling's 
solution  may  also  be  used  in  bulk,  some  of  the  filtrate 
being  floated  on  its  surface,  when  a  pink  ring  at  the 
point  of  contact  appears  if  these  bodies  be  contained 
in  the  liquid.  This  is  not  nearly  so  delicate  a  method, 
and  seldom  a  negative  proof,  if  the  proteids  be 
small  in  amount,  requiring  corroboration  by  other 
means. 

The  biuret  reaction,  it  should  be  remembered,  can- 
not  be    obtained   in    any  solution    to  which  phenol- 


TESTS    FOR    PROTEIDS  IO3 

phthalein  has  been  previously  added,  the  alkali  giving 
that  dye  a  colour  similar  to  the  pink  caused  by  the 
lower  proteids. 

The  xantho-proteic  reaction  may  also  be  em- 
ployed. 

A  small  quantity  of  the  liquid  is  heated  in  a  porce- 
lain basin  with  strong  nitric  acid,  allowed  to  cool,  and 
some  ammonia  added.  If  proteids  are  present  a 
reddish-orange  colour  appears. 

These  last  tests  only  serve  to  tell  us  whether  albu- 
moses  or  peptones  are  present.  To  ascertain  whether 
the  proteid  be  of  the  nature  of  an  albumose  or  of  a 
peptone,  or  if  both  are  contained  in  the  liquid,  the 
filtrate  after  the  removal  of  the  albumin  is  boiled, 
rendered  slightly  acid,  and  saturated  at  the  boiling 
point  with  neutral  sulphate  of  ammonium  [(NH4)2  SO^.] 
The  albumoses  are  precipitated,  and  can  be  separated 
from  the  still  soluble  peptone  by  filtration,  and  wash- 
ing the  precipitate  on  the  filter  paper  with  hot 
saturated  ammonium  sulphate  solution. 

The  persistence  of  the  biuret  and  xantho-proteic 
reactions  in  the  filtrate  denotes  the  presence  of 
peptone. 

If  the  nature  of  the  albumoses  caught  on  the  filter 
paper  is  of  moment  or  interest,  they  may  be  dissolved 
up  in  hot  water,  the  resulting  solution  concentrated 
and  saturated  with  chloride  of  sodium. 

The  primary  albumoses  are  precipitated,  proto-  and 
hetero-albumose ;  the  secondary  albumose,  deutero- 
albumose,  remains  in  solution. 

The  ammonium  sulphate  and  chloride  of  sodium 
may  be  removed  by  dialysis  from  both  solutions,  and 
the  proteids  obtained  in  a  nearly  pure  state.     Hetero- 


I04  TESTS    FOR    PROTEIDS 

albumose  can  be  separated  from  proto-albumose  by- 
taking  advantage  of  its  insolubility  in  distilled  water, 
in  which  the  latter  is  soluble.  The  precipitation  of 
hetero-albumose  by  the  removal  of  salts  from  the  solu- 
tion is  rendered  more  complete  by  the  application  of 
heat. 

A  rapid  and  easy  method  to  ascertain  the  forms  of 
proteid  bodies  in  the  stomach  contents  is  : — i.  To  test 
for  acid  albumin  as  above.  2.  To  add  an  equal 
quantity  of  10  per  cent,  trichloracetic  acid 
(C2HCI3O.2.)  This  precipitates  proto-albumose  in 
the  cold,  and  coagulates  all  albumins  and  globulins. 
If  the  solution  now  be  boiled  and  filtered  while  hot, 
the  proto-album.ose  dissolves  up  and  passes  through 
along  with  deutero-albumose  and  peptone.  The 
usual  tests  will  reveal  their  presence  or  absence.  On 
cooling,  the  proto-albumose  in  the  filtrate  again  separ- 
ates out. 

Mucin  and  nucleo-albumins  may  be  present  in  the 
filtrate  when  the  acidity  is  low  and  the  digestive 
power  weak.  In  fluids  obtained,  or  regurgitated,  from 
oesophageal  pouches,  the  presence  of  mucin  in  con- 
siderable amount  may  aid  in  the  diagnosis. 

The  addition  of  a  very  small  quantity  of  acetic  acid, 
just  enough  to  render  the  solution  acid,  precipitates 
mucin.  The  specimen  to  which  the  acid  is  added 
should  be  allowed  to  stand  for  twenty-four  hours, 
when  the  precipitate,  if  any,  will  be  apparent.  This 
precipitate  is  insoluble  in  excess  of  the  acid.  A 
similar  precipitate  from  the  nuclein  in  nucleo- 
albumin  occurs,  but  this  is  soluble  in  excess. 

Nucleo-albumins  are  acted  on  by  active  gastric 
juice,  the  proteid  portion  being  digested  like  other 


SALIVA  105 

albumins,  the  nuclein  left.  As  this  is  insoluble  in  an 
acid  medium,  it  does  not  appear  in  the  filtered  contents 
of  the  stomach. 


Tests   for   Sugar  and   Starch   in   the  Stomach 
Contents. 

It  will  not  be  necessary  to  enter  into  all  the 
particulars  of  the  tests  for  sugar,  or  for  starch,  in  this 
place.  Sugar  is  at  once  detected  by  the  reduction  of 
Fehling's  solution  when  boiled  with  some  of  the 
filtered  contents,  deprived  of  proteid  bodies  ;  starch, 
by  adding  a  drop  of  the  contents  to  a  mixture  of 
iodine,  iodide  of  potassium,  and  v/ater,  when  the 
appearance  of  a  blue  colour  indicates  its  presence,  of  a 
violet,  erythrodextrin. 

Saliva. 

In  some  instances  it  is  of  importance  to  know  whether 
the  fluids  vomited  or  removed  from  the  stomach  are 
composed  of  gastric  secretion,  or  of  saliva  which  has 
been  swallowed  and  regurgitated,  as  in  cases  of  water- 
brash,  or  with  oesophageal  pouches.  If  chiefly  com- 
posed of  saliva  the  reaction  will  be  slightly  alkaline, 
neutral,  or  perhaps  very  slightly  acid.  A  few  c.  c. 
added  to  some  starch  solution,  and  kept  at  38'^  C.  for 
about  twenty  minutes,  will  convert  some  of  the  starch 
into  dextrins  or  maltose,  as  evidenced  by  the 
colour  produced  on  the  addition  of  the  iodine  and 
iodide  of  potassium  solution  ;  and  lastly,  the  addition  of 
dilute  perchloride  of  iron  to  some  of  the  fluid, .  which 
should  be  first  rendered  slightly  acid  with  the  merest 


I06  TOXINES    IN    GASTRIC    CONTENTS 

trace  of  hydrochloric  acid,  causes  the  development  of  a 
red  colour  owing  to  the  presence  of  sulphocyanide  of 
potassium.  This  red  colour  disappears  on  the 
addition  of  mercuric  chloride,  unlike  the  similar 
colour  yielded  by  meconic  acid  in  cases  of  opium 
poisoning.  Colosanti  *  advocates  precipitation  of  the 
saliva  with  alcohol,  filtration,  evaporation  of  the 
filtrate  to  dryness,  solution  of  the  residue  in  water, 
and  the  addition  of  copper  sulphate.  If  sulpho- 
cyanide of  potassium  be  present,  a  bright  emerald 
green  develop  es. 

Toxines   in   the   Gastric   Contents. 

For  the  separation  and  study  of  the  toxines  present 
in  the  stomach  contents,  Turck  7  recommends  the 
withdrawal  of  the  stomach  fluid  either  before  break- 
fast or  after  a  preliminary  washing  out,  and  the 
introduction  of  starch  or  albumin  onh'.  The  fluid 
obtained  is  filtered  through  a  sterilised  Pasteur  filter, 
and  the  filtrate  concentrated  under  a  vacuum  pump. 
The  degree  of  concentration  is  measured,  and  a 
quantity  corresponding  to  i  c.c.  of  the  original  fil- 
trate injected  into  an  animal  for  each  1000  grammes  of 
its  body-weight.  This  proportion  is  gradually  increased. 
The  unused  portion  of  the  fluid  is  now  heated  to  136^ 
or  158''  F.  under  a  vacuum  for  four  hours.  The 
proteids  coagulated  by  this  temperature,  which  does 
not  destroy  bacterial  products,  are  filtered  off,  and  the 
new  filtrate  injected  as  before.  The  products  of 
the    growth  of  the  organisms    grown  from  the   con- 

*  yioXy^s  Jahresbei- .,  xix,  72,  1890. 

J  AW  York  Med.  Journ.,  Feb.  22,  1896,  p.  233. 


TOXINES    IN    GASTRIC    CONTENTS  lOj 

tents,  and  cultivated  in  boullion,  are  similarly  treated 
and  injected. 

The  toxic  effects  of  the  filtered  and  sterile  stomach 
contents  are  due  to  two  factors  :  to  albumoses,  or 
other  protelds  in  them,  or  to  bacterial  products.* 

*  Vide  also  Cissaet  et  Terre,  Coinpt.  Rend.  d.  I'Soc.  d.  Biologie,   1894, 
pp.  532  and  633. 


CHAPTER  VIII 

THE  DETERMINATION    OF  THE   MOTILITY,  SIZE, 
AND   POSITION  OF  THE   STOMACH. 

The  Motility — Salol  (Ewald,  Ruber) — Oil  (Klemperer) — Gastrograph 
(Einhorn)  —  Kymograph  (Hemmeter)  —  Power  of  Absorption — 
Potassium  Iodide  (Penzoldt) — Rhubarb — Size  and  Position — Fill- 
ing Stomach  with  Water — With  Gas— With  Air — Clapotement — 
Determination  of  the  exact  quantity  of  the  Stomach  Contents. 

The  Motility  of  the  Stomach. 

Several  tests  have  been  devised  for  the  purpose  of 
determining  the  motor  function  of  the  stomach. 
Leube  has  suggested  that  the  presence  or  absence  of 
soHd  contents  a  definite  period  of  six  to  seven 
hours  after  a  large  meal,  or  of  two  to  two  and  a  half 
hours  after  Ewald's  test-breakfast,  might  serve  as  an 
indication  of  the  power  of  that  organ  to  empty  the 
food  into  the  duodenum.  That  is  to  say,  if  the 
stomach  is  empty  at  these  hours,  its  motility  may  be 
regarded,  according  to  him,  as  normal ;  if  there  is  still 
some  solid  material  in  it,  the  motility  is  weakened. 
This  method,  however,  is  subject  to  fallac}',  depends 
upon  the  nature  of  the  food  taken,  requires  the  use  of 
the  stomach-tube,  and  takes  no  account  of  the  process 
of  absorption  as  well  as  that  of  motility. 

Ewald  *  has  proposed  the  use  of  salol.     Salol  is  a 

"  Therapeiitische  Monatshefte,  August  18S7. 


MOTILITY    OF    THE    STOMACH  IO9 

compound  of  carbolic  and  salicylic  acids,  a  phenol- 
ether  of  salicylic  acid,  which  is  said  not  to  be  changed 
by  acid  solutions,  but  to  be  converted  in  alkaline  fluids 
into  salicylic  acid  and  phenol.  Ewald  imagined  that, 
if  this  supposition  was  true,  salol  would  prove  an  ex- 
cellent means  for  determining  how  rapidly  substances 
pass  into  the  duodenum  from  the  stomach,  and,  in 
addition,  might  help  to  show  if  the  action  of  the 
pancreas  and  the  intestinal  cells  were  normal,  as  the 
salol  would  not  be  affected  by  the  acid  of  the  gastric 
juice,  but  would  be  split  up  in  the  duodenum ;  its 
derivatives  absorbed  and  excreted  in  the  urine.  When 
salol  has  been  decomposed  into  the  two  acids  above 
named,  the  salicylic  acid,  absorbed  into  the  blood, 
appears  in  the  urine  as  a  further  decomposition  pro- 
duct, viz.,  salicyluric  acid. 

Normally,  salicyluric  acid  can  be  detected  in  the 
urine  forty  to  sixty,  or,  at  most,  seventy-five  minutes 
after  gr.  15  (i  grm.)  of  salol  has  been  given  during 
the  course  of  digestion.  Any  delay  in  the  appear- 
ance of  the  acid  in  the  urine  will  indicate  some  re- 
tardation of  the  time  taken  by  the  stomach  to  empty 
itself.  The  salol  is  best  given  in  gelatine  capsules,  to 
guard  against  any  action  of  the  alkali  in  the  saliva  on 
it,  and  which  readily  dissolve  in  the  stomach.  Salicy- 
luric acid  may  be  recognised  by  the  violet  colour, 
similar  to  that  produced  in  the  formation  of  Uffel- 
mann's  reagent,  on  the  addition  of  a  neutral  solution 
of  perchloride  of  iron.  To  detect  the  first  trace  of  the 
acid  some  of  the  urine  should  be  rendered  acid  with 
hydrochloric  acid,  shaken  up  with  ether,  and  the 
ether  extract  tested  with  the  iron  solution,  as  the 
salicyluric  acid  readily  combines  with  the  ether  used. 


no  MOTILITY    OF    THE    STOMACH 

A  simple  method,  recommended  by  Ewald,  is  to 
place  a  drop  of  the  urine  on  a  filter  paper  and  then 
let  a  drop  of  lo  per  cent,  solution  of  chloride  of  iron 
fall  upon  the  moistened  spot.  Where  the  iron  solution 
touches  the  moistened  surface,  a  violet  colour  appears 
if  there  is  even  the  smallest  trace  of  salicyluric  acid 
present. 

This  test,  however,  is  of  little  practical  value. 

Ewald,  indeed,  states  that  the  reaction  is  obtained, 
in  the  great  majority  of  a  large  series  of  experiments, 
between  sixty  to  seventy-five  minutes  after  the  salol 
has  been  taken.  Other  observers,  however,  have 
obtained  very  various  results,  and  if  Stein's  observation 
is  correct,*  viz.,  that  salol  is  absorbed  by  the  mucous 
membrane  of  the  stomach,  although  it  is  not  decom- 
posed in  that  organ,  and  that  it  may  appear  in  the 
urine  in  the  form  of  salicyluric  acid  before  its 
entrance  into  the  bowel,  the  method  can  hardly  be 
regarded  as  accurate.  Stein  has  obtained  this  reac- 
tion in  dogs  with  duodenal  fistulse  before  the  con- 
tents of  the  stomach  reached  the  bowel,  and  in  cases 
where  there  was  no  evidence  of  any  decomposition  of 
the  salol  in  the  stomach. 

Huber  t  estimates  the  motility  of  the  stomach  wall 
by  the  same  drug,  but  in  a  different  manner.  He 
determines  how  long  the  salicyluric  acid  reaction  in 
the  urine  lasts.  He  finds  that  traces  of  this  acid  may 
be  found  in  healthy  people  for  24  hours  after  inges- 
tion, while  in  those  in  whom  enfeeblement  of  the 
muscles  of  the  stomach  wall  is  present  salicyluric 
acid  can  be  detected  48  hours  or  even  longer  after 

"''  Wien.  med.   Wochen.  43,  1892. 

J  MiiJich.  med.  Wochen.,  1887,  No.  19, 


MOTILITY    OF    THE    STOMACH  I  I  I 

administration.  Here,  again,  it  is  difficult  to  say  what 
portion  of  the  time  taken  is  dependent  on  the  move- 
ments of  the  stomach  wall,  and  what  portion  on  delay 
of  intestinal  absorption.  To  carry  out  Ruber's  test, 
the  urine  should  be  examined  24  to  30  hours  after 
the  salol  has  been  given,  and  if  salicyluric  acid  is  still 
present  at  the  latter  period  (or  later),  we  may  infer 
that  there  is  some  disturbance  of  the  motor  activity 
of  the  stomach. 

Klemperer"^  has  proposed  still  another  method  for 
determining  the  motor  activity  of  the  stomach.  He 
introduces  a  definite  quantity,  looc.  c.  (a  little  more 
than  2  oz.)  of  pure  olive  oil  into  the  empty  stomach, 
which  may  be  washed  out  beforehand  if  necessary. 
Two  hours  afterwards  the  oil  is  removed  by  the 
stomach-tube  as  completely  as  is  possible,  and  the 
difference  between  the  quantity  originally  introduced 
and  that  obtained  after  the  two  hours  is  regarded  by 
him  as  an  indication  of  the  gastric  motility.  This 
method  is  of  doubtful  value,  and  to  many  patients 
very  objectionable. 

Einhorris  Gastrograph.\ — One  of  the  many  instru- 
ments introduced  by  Einhorn,  the  gastrograph,  consists 
of  a  stomach-tube  with  a  hollow  ball  at  the  lower  end 
containing  a  free  ball  of  platinum.  (Fig.  V.)  By  the 
movements  of  the  stomach  walls  the  platinum  ball  is 
moved  about  in  the  bulb,  coming  in  contact  with  the 
terminals  of  an  electric  circuit  therein,  and  by  break- 
ing and  making  the  current,  signals  the  occurrence 
of  gastric  movements  on  a  suitable  apparatus  outside. 

Heminetei''s  KymograpJi.  —  Einhorn's    gastrograph 

*  Deutsche  med.  Wochenschr.,  1887,  No.  47, 
t  Zeitschr.f.  klin.  Med.,  xxvii.  3I4,  s.  242. 


112  PO^YER    OF    ABSORPTION 

only  records  the  acti\-e  movements  of  the  stomach, 
and  Hemmeter  has  devised  another  method  for  test- 
ing both  the  active  and  passive  gastric  peristalsis. 
Moritz  of  ]\Iunich  has  independently  conceived  and 
described  a  similar  apparatus. 

A  deglutable  elastic  stomach-shaped  bag  of  thin 
rubber  is  attached  to  the  end  of  a  stomach-tube.  It 
is  introduced  while  collapsed,  and  then  blown  up  with 
air.  The  outer  end  of  the  tube  is  then  attached  to  a 
manometer  or  tambour,  and  the  movements  of  the 
stomach  walls,  however  slight,  can  be  registered  on 
paper  attached  to  a  revolving  drum.  A  time  record 
is  also  kept  on  the  paper,  and,  as  the  movements  of 
respiration  affect  the  size  of  the  stomach,  a  separate 
line  indicates  the  respiratory  movements,  as  recorded 
by  a  pneumograph  (see  p.  162). 

The  methods  recommended  for  the  determination 
of  the  motility  of  the  stomach  can  seldom  be  em- 
ployed, except  in  cases  where  the  motor  insufficiency 
gives  rise  to  such  characteristic  symptoms  that  the 
evidence  they  afford  can,  as  a  rule,  be  only  corrobora- 
tive. 

The  Po-wer  of  Absorption  of  the  Stomach. 

The  absorptive  power  of  the  gastric  mucous  mem- 
brane may  be  tested  with  potassium  iodide.  Penzoldt* 
recommends  small  doses  of  this  salt,  o*i  grm.  (gr.  i|), 
enclosed  in  gelatine  capsules.  A  capsule  is  given, 
and  the  time  which  elapses  before  iodine  appears  in 
the  saliva  is  determined  by  means  of  the  ordinary 
reaction  with  starch  paste'.  To  perform  this  test  a 
filter  paper  should   be   moistened  with   starch   paste 

*  Penzoldt  and  Faber,  Berliner  klin,  Wochenschr.^  1882,  No.  21. 


Fig.  5. — Einhorn's  Gastrograjjli.    (See  page  111.) 


Fig.  6.— Einhorn's  Gastric  Spray.    (See  page  121.) 


Fig.  7. — Einhorn's  Deglutable  Electrode. 
(See  page  127.) 


SIZE    AND    POSITION    OF    STOMACH  I  1 3 

and  dried,  and  every  five  minutes  after  the  capsule 
has  been  taken,  a  drop  of  the  saliva  placed  upon  it. 
The  addition  of  a  drop  or  two  of  fuming  nitric  acid  will 
cause  the  appearance  of  a  blue  colour  when  iodine  is 
secreted  in  the  saliva.  The  time  which  elapses  before 
this  reaction  can  normally  be  obtained  varies  from 
ten  to  fifteen  minutes,  but  may  be  delayed  from  thirty 
minutes  to  a  whole  hour,  or  even  longer,  when  the 
absorptive  power  of  the  gastric  mucous  membrane  is 
diminished.  It  should  be  remembered  in  connection 
with  the  test  that,  if  the  capsule  be  given  without 
food,  it  may  pass  almost  at  once,  indeed  before  solu- 
tion of  the  gelatine,  into  the  duodenum.  It  should, 
therefore,  be  always  administered  with  or  soon  after 
food. 

Another  test  makes  use  of  rhubarb.  Two  grains 
of  powdered  rhubarb  are  given,  and  fifteen  minutes 
afterwards  the  addition  of  liquor  potassje  to  the  urine 
should  cause  the  formation  of  a  red  colour. 

Before  using  any  of  these  tests  in  which  the  appear- 
ance of  the  drug  in  the  urine  is  noted,  it  is  necessary 
to  be  sure  that  the  patient  has  not  emptied  his  bladder 
immediately  beforehand. 

Tlie  Size  and  Position  of  the  Stomach, 

A  description  of  the  usual  clinical  methods  for  the 
determination  of  the  size  and  position  of  the  stomach 
does  not  enter  into  the  scheme  of  this  book.  There 
are  several  methods,  however,  which  may  be  legitim- 
ately described  under  this  heading,  without  trenching 
on  the  purely  clinical  aspect. 

One  of  the  earliest  instruments  suggested  for  the 
determination  of  the  lower  margin  of  the  stomach 

H 


114  SIZE    AND    POSITION    OF    STOMACH 

consisted  simply  of  a  rigid  bougie,  the  point  of  which 
could  be  felt,  after  introduction,  through  the  abdo- 
minal wall.  This  method  was  found  to  be  not  unat- 
tended with  risk,  and  has  consequently  been  aban- 
doned. 

Einhorn's  Gastrodiaphanoscope  and  Turck's  Gyro- 
mele  are  described  elsewhere  (pp.  132,  161). 

When  instruments  cannot  be  used,  Dehio*  directs 
that  the  patient  should  be  percussed  both  when  lying 
down  and  when  erect,  after  drinking  various  quan- 
tities of  water.  He  says  that  the  normal  stomach 
when  empty  is  entirely  within  the  thorax,  and  is  not 
percussible  ;  that  a  quarter  of  a  litre  of  water  produces 
a  dull  area,  extending  1 1 J  cm.  below  the  xiphi-sternum, 
in  the  erect  posture  ;  and  that  a  second  draught  of  the 
same  amount  lowers  the  dullness  to  27  cm.  A  litre 
causes  it  to  reach  to  almost  the  level  of  the  umbilicus, 
generally  to  within  an  inch  of  that  spot. 

On  the  other  hand,  Jaschtschenkof  avers  that  the 
empty  and  normal  stomach  is  percussible,  and  that 
filling  it  with  water  causes  an  upward,  not  a  down- 
ward, extension  of  dullness. 

In  cases  where  much  difficulty  is  experienced  in 
distinguishing  the  percussion  note  of  the  stomach 
from  that  of  the  colon,  the  stomach  may  be  filled  with 
water,  and  the  colon  with  air  per  aiinin,  when  the 
sharp  demarcation  between  the  dull  note  of  the 
stomach  and  the  tympanitic  resonance  of  the  bowel 
can  readily  and  accurately  be  determined. 

If  the  colon  be  loaded,  the  reverse  method  may  be 
used.     The  patient  is  given  some  bicarbonate  of  soda 

*  Separat  Abdruck  aus  den  Verkandlufigen  des  Congresses  f.  innere  Med. 
■\  Si  Petersburg  nied.   Woc/i.,  29,  1888. 


SPLASHING    SOUND  I  I  5 

in  solution,  and  then  a  corresponding  amount  of 
tartaric  acid.  The  evolution  of  carbonic  acid  gas, 
which  resuhs,  expands  the  stomach,  and  renders  the 
percussion  note  over  it  tympanitic,  in  marked  contrast 
to  the  dull  note  of  the  loaded  colon.  Another  way  is 
to  pass  the  stomach  tube  and  expand  the  stomach  by 
blowing  down  it,  and  has  the  merit  of  being  quite  free 
from  risk. 

Fleming  *  suggests  a  method  of  combined  percus- 
sion and  auscultation,  whereby  the  slightest  change  in 
the  note  can  be  •  detected  by  a  stethoscope  placed 
over  the  stomach  region,  where  it  is  uncovered  save  by 
the  abdominal  wall. 

Splashing  Sound,  or  Clapotement. 

The  sound  caused  by  the  movements  of  the  gastric 
contents  when  the  body  is  shaken,  or  the  abdominal 
wall  over  the  stomach  strongly  percussed,  indicates 
the  presence  of  both  fluid  and  gas  in  it.  It  is  often 
obtainable  in  healthy  subjects,  and  indicates  nothing 
unless  the  sounds  be  abnormally  loud,  or  ob- 
tainable by  percussion  below  the  normal  lower  limit 
of  the  stomach.  Percussion  for  this  purpose  is  best 
performed  with  the  edge  of  the  hand  ;  but  in  some 
cases  of  dilated  stomach,  with  thin  and  lax  parietes, 
tapping  with  the  finger  may  suffice  to  produce  it. 
Normally,  percussion  elicits  a  splashing  sound  not 
lower  than  midway  between  the  sternum  and  the  um- 
bilicus, and  then  it  is  only  feeble.  In  atonic  condi- 
tions the  splashing  sounds  are  heard  in  the  same 
region,  but  may  persist  for  four  to  six  hours  after  a 

*  Edin.-Hosp.  Reports^  Vol.  I. 


Il6  EXACT    QUANTITY    OP^ 

meal,  denoting  delayed  emptying.  In  simple  enlarged 
stomach  —  Ewald's  megalogastria  —  the  splashing 
sound  may  be  produced  as  far  down  as  the  umbilicus, 
while  in  cases  of  pronounced  dilatation  it  may  be 
elicited  more  or  less  over  the  whole  of  the  anterior 
abdominal  surface.  The  localisation  of  splashing 
sounds  to  a  somewhat  circumscribed,  area  about  the 
umbilicus  and  below  it,  and  the  absence  of  these 
sounds  higher  up,  are  suggestive  of  possible  gastro- 
ptosis.  But  it  must  be  remembered  that  forcible 
percussion  of  one  part  of  the  abdomen  often  suffices 
to  elicit  splashing  sounds,  although  the  stomach  does 
not  occupy  a  position  directly  beneath  it.  The  actual 
spot  under  which  the  sound  is  produced  can  in  some 
cases  be  more  accurately  determined  by  combining 
auscultation  with  percussion.  Another  point  to  be 
kept  in  mind  is  the  frequent  disappearance  of 
"  clapotement "  sounds  after  the  first  few  strokes, 
owing  to  the  resultant  stimulation  of  the  muscles  in 
the  gastric  walls,  and  their  consequent  contraction. 

The   Determination   of  the   exact  quantity  of  the 
Stomach  Contents. 

As  a  rule  the  quantity  of  chyme  can  be  estimated 
from  the  amount  of  fluid  obtained  through  the 
stomach  tube.  In  many  cases,  especially  where  the 
stomach  walls  are  lax,  all  the  fluid  cannot  be  with- 
drawn. Mathieu  and  Remond  *  suggest  that  in  such, 
circumstances  a  small  portion  of  the  contents  should 
be  removed  through  the  stomach  tube,  and,  without 
removing   the   tube,    a   measured    amount   of    water 

*  Sec.  de.  Biologic,  Nov.  8,  189c. 


STOMACH    CONTENTS  I  I  7 

poured  down  it.  The  patient  now,  by  shaking  him- 
self, etc.,  mixes  the  water  and  the  stomach  contents, 
a  sample  of  which  is  withdrawn. 

The  difference  between  the  acidities  of  the  undi- 
luted and  the  diluted  samples  affords  evidence  of 
the  total  quantity  present. 

Thus,  if  b  represent  the  undiluted  portion  ;  a,  its 
acidity ;  q,  the  amount  of  water  added,  and  a  the 
acidity  of  the  diluted  contents  : 

ax  =   c'lq    +  ax 

aq  ,  ,         aq 

or        X  =  — -,   so  that  x  =  b  +  — — , 
a  -  a  a  -  a 

That  is,  the  quantity  of  the  original  contents  is 
equal  to  the  number  of  c.  c.  of  water  added,  multi- 
plied by  the  acidity  present  after  its  addition,  divided 
by  the  result  of  subtracting  the  second  acidity  from 
the  first,  and  adding  the  portion  withdrawn  on  the 
first  occasion. 


Example. 

Ten  c.  cm.  withdrawn  with  an  acidity  of  0"365  per  cent.     200 

c.  cm.  of  water  added,  and  another  sample  withdrawn  with  an 

acidity  of  0-3285  per  cent. 

o'32  85,x  200  . 

X  =  10  +  ~^> — ~ pr-  =  1810  c.  cm. 

0-365 -0-3285 


CHAPTER  IX. 

THE  MECHANICAL  METHODS  USED  IN  THE 
TREATMENT  OF  THE  DISEASES  OF  THE 
STOMACH^ 

Lavage  —  Auto-lavage  —  Friedlieb's  Apparatus  —  Gastric  Spray 
(Einhorn) — Needle  Douche  (Turck) — Treatment  by  Electricity — 
Apparatus — External  Electrisation — Internal  Electrisation — Illumi- 
nation of  the  Stomach — Diaphanoscope  (Einhorn) — Other  Instru- 
ments— Gyromele  (Turck,  Boas) — Massage. 

The  Process  of  Washing  Out  the  Stomach  (Lavage). 

The  method  of  introducing  the  stomach  tube  has 
already  been  described.  It  only  remains,  therefore, 
to  add  a  few  particulars  concerning  the  process  of 
washing  out  the  stomach.  After  the  tube  has  been 
passed  down  and  some  of  the  contents  of  the  stomach 
removed  for  the  purpose  of  analysis,  warm  water  is 
introduced  into  the  stomach,  until  the  patient  signifies 
uneasiness  from  distension  of  the  organ.  The  funnel 
is  then  depressed,  and  the  fluid  with  the  remaining 
portion  of  the  contents  syphoned  off  into  a  pail  or 
basin.  This  process  is  repeated  until  the  water  re- 
turning through  the  tube  is  clear.  As,  in  many 
instances,  the  pouring  of  the  water  into  the  funnel 
carries  down  a  considerable  proportion  of  air  with  it 
into  the  stomach,  often  causing  the  patient  much  pain 


LAVAGE  I  I  9 

and  discomfort,  and  as  this  air  is  frequently  expelled 
through  the  tube  again  at  unexpected  moments,  it  is 
a  good  plan  to  hold  the  funnel  in  the  left  hand,  and, 
compressing  the  tube  just  below  with  the  little  finger, 
to  only  allow  the  water  to  pass  slowly  down  when  the 
funnel  is  full.  -  If  this  is  not  done,  and  the  water  is 
allowed  to  run  down  as  fast  as  it  is  poured  in,  much 
air  is  carried  down  with  it.  If  the  return  flow  of 
water  from  the  stomach  is  checked  at  any  time, 
generally  owing  to  blocking  of  the  eyes  of  the  tube 
with  solid  particles  in  the  contents,  the  funnel  should 
be  raised,  a  little  more  water  poured  down  to  dislodge 
the  obstruction,  and  the  funnel  again  depressed. 
Usually  some  small  portion  of  the  fluid  introduced 
remains  behind  when  syphonage  alone  is  relied  on  to 
empty  the  stomach.  In  this  case  expression  by 
pressure  over  the  epigastrium  may  be  resorted  to. 

Several  solutions  have  been  recommended  to  be 
used  for  washing  out  the  stomach.  The  best  seems 
to  be  one  made  by  adding  a  few  drops  of  a  solution 
of  permanganate  of  potash  to  warm  water  until  it  be- 
comes light  pink  in  colour.  A  3  per  cent,  solution  of 
boric  acid,  2  to  4  per  cent,  of  bicarbonate  of  sodium, 
or  a  I  per  cent,  solution  of  common  salt  may  also  be 
used.  The  permanganate  of  potash  solution  has  this 
advantage  over  the  others,  that  when  the  stomach 
is  thoroughly  washed  out  and  all  the  contents  re- 
moved, the  returning  fluid  retains  a  pink  colour ;  but 
should  any  of  the  contents  still  remain,  the  fluid  re- 
turned is  of  a  brown  hue. 

Aiito-lavage. — The  foregoing  method  cannot  be 
used  by  the  patient  himself  When  a  patient,  there- 
fore, is  instructed  to  personally  continue  the  process 


I20  AUTO-LAVAGE 

of  lavage,  another  method  is  called  for.  In  this,  the 
stomach  tube  is  connected  bv  a  glass  T  or  Y  tube  to 
a  rubber  tube  running  from  a  reservoir  filled  with  the 
warm  solution  to  be  used,  and  to  another  leading 
into  the  receiving  pail  (Frontispiece).  The  rubber  tube 
Heading  from  the  reservoir  is  furnished  with  a  pressure 
clip  close  above  the  upper  limb  of  the  T  or  Y  tube, 
and  a  similar  clip  is  placed  on  the  corresponding  part 
of  the  lower  tube,  rather  further  away  from  the  glass 
connection  (see  p.  165  Appendix). 

The  reservoir,  for  which  an  ordinary  metal  douche- 
can  may  be  advantageously  employed,  capable  of  con- 
taining at  least  two  litres,  is  filled  with  the  warmed 
solution  and  hung  on  to  a  nail  fixed  in  the  wall  a 
little  above  the  level  of  the  patient's  head  when 
sitting  down.  The  clip  on  the  tube  leading  from  it 
must  be  closed  beforehand.  The  tube  leading  from 
the  lower  limb  of  the  T  is  conducted  into  a  pail 
placed  on  the  floor,  or  directly  into  a  sink,  if  con- 
venient.    The  clip  upon  this  tube  is  also  closed. 

The  patient  now  introduces  the  stomach  tube, 
attaches  the  upper  end  to  the  free  limb  of  the  T  tube, 
and  pressing  the  clip  on  the  tube  leading  from  the 
reservoir,  allows  the  warm  water  to  enter  the  stomach. 
When  the  stomach  is  full  of  fluid,  the  lower  clip  is 
opened  a  short  time  before  the  upper  is  closed. 
The  water  from  the  reservoir  at  once  fills  the  lower 
tube  in  preference  to  that  going  to  the  stomach, 
following  the  path  of  least  resistance,  and  if  the 
upper  clip  be  now  closed,  syphon  action — sufficient 
to  empty  the  stomach  through  the  lower  tube — is 
started.  This  process  is  repeated  until  the  outgoing 
fluid  is  clear  or  almost  clear. 


AUTO-LAVAGE  121 

-  Friedlich's  Apparatus.  —  Another  very  simple 
method  by  which  auto-lavage  can  be  satisfactorily 
performed  is  by'  Friedlieb's  apparatus.  This  consists 
of  a  stomach  tube  jDrovided  with  a  bulb  at  a  part 
sufficiently  far  from  the  end  of  the  tube  to  remain 
outside  the  lips  after  introduction  of  its  extremity 
into  the  stomach.  Compression  of  the  bulb,  followed 
by  closure  of  the  tube  beyond  it  by  pressure  of  the 
fingers,  causes,  by  its  succeeding  expansion,  the 
stomach  contents  to  be  drawn  up  into  it.  Closure 
of  the  tube  between  the  bulb  and  the  lips  and  com- 
pression of  the  bulb  forces  the  contents  out  through 
the  funnel  at  the  distal  end.  The  bulb  need  only 
be  used  if  ordinary  syphonage  proves  to  be  insuffi- 
cient. 

Einhorn's  Gastric  Spray*  This  instrument  consists 
of  a  stomach  tube  in  which  the  usual  eyes  are  re- 
placed by  a  terminal  bulb,  having  at  its  extremity  a 
small  aperture  (Fig.  VI.).  The  tube  is  introduced 
into  the  stomach,  which  must  be  empty — ie.,  after 
lavage  or  fasting— the  outer  end  attached  to  a  spray- 
producer,  and  the  indiarubber  pump  compressed  in 
the  ordinary  way.  The  spray  should  be  set  in  action 
whenever  the  nozzle  has  entered  the  cardiac  orifice ; 
that  i.s,  when  the  tube  has  been  passed  in  beyond  the 
teeth  of  the  patient  for  a  distance  of  i8  inches 
(45  cm). 

Antiseptic,  analgesic,  and  astringent  solutions  may 
be  used  for  spraying  the  stomach  in  this  manner. 
The  inventor  employs  a  i  to  2  per  thousand  solution 
of  silver  nitrate,  10  c.c.  at  a  sitting,  in  cases  of  gastric 

*  New  York  Afed.Journ.,  Sept.  1892. 


122  LAVAGE     - 

erosions,*    or    of    hypersecretion    with    hyperchlor- 
hydria.-j- 

Tiirck's  Needle-Douche. — Dr  Turck  demonstrated 
an  apparatus  which  he  called  a  '  stomach  needle- 
douche  '  at  the  meeting  of  the  American  Medical 
Association  in  May  1895.  Two  tubes  are  attached  to 
each  other,  side  by  side.  One  is  of  smaller  calibre 
than  the  other,  and  is  only  intended  to  reach  the 
stomach  cavity  immediately  beyond  the  cardiac  orifice. 
The  larger  is  continued  further,  and  should  extend  as 
far  as  the  lowest  part  of  the  larger  curvature.  The 
smaller  and  shorter  tube  is  supplied  with  a  small  per- 
forated bulb  at  its  extremity,  or  is  perforated  by 
minute  holes  towards  the  lower  end,  where  it  termin- 
ates in  a  blind  extremity.  The  ball  or  bulb  possesses 
the  advantage  that  it  can  be  removed  and  cleaned, 
and  that  the  tubes  may  be  used  without  it,  a  nebulizer 
being  employed  instead.  Hot  or  cold  water,  or  both 
alternately,  are  forced  through  the  smaller  tube  under 
the  pressure  of  a  force-pump.  A  shower  bath  is  thus 
produced  in  the  stomach,  and,  if  considerable  pressure 
be  employed,  mucus  and  adherent  material  can  be 
removed  from  the  walls,  and  a  powerful  vasomotor 
and  muscular  stimulating  action  induced.  The  larger 
tube  serves  to  drain  off  the  fluid  introduced,  and 
thus  to  prevent  any  overdistension  of  the  stomach 
{c.f.  Fig.  XIV.,  p.  164). 

Indications  for  Lavage. 

Lavage  is  of  service,  apart  from  its  value  for  diag- 
nostic purposes,  whenever  stagnation  of  food  in  the 

*  Berlin,  klin.   Wochejisck.,  20-21,  1895. 
t  Med.  Record,  Nov.  23,  1895. 


INDICATIONS    FOR    LAVAGE  1 23 

stomach  is  present,  when  there  is  much  mucus  in  the 
organ,  in  cases  of  hyperacidity,  and  in  many  of  the 
various  forms  of  nervous  dyspepsia.  In  cases  of 
nervous  origin  the  mere  act  of  washing  out  the 
stomach  is  often  followed  by  a  great  amelioration  of 
the  symptoms,  owing  more,  perhaps,  to  stimulation  of 
the  nervous  system  and  to  mental  suggestion  than  to 
the  actual  removal  of  contents  which  are  often  normal 
in  character. 

Some  recommend  lavage  in  the  morning  before  or 
after  breakfast  ;•  others  prefer  the  evening  before  bed- 
time. In  severe  cases  of  dilated  stomach  with  hyper- 
secretion, it  may  be  required  before  breakfast  and 
before  the  evening  meal,  to  remove  the  stagnating 
remains  of  food  and  to  permit  of  the  digestion  of  the 
food  under  as  favourable  circumstances  as  possible. 

If  the  patient  suffers  from  insomnia  or  restlessness 
during  the  night  from  auto-intoxication  due  to  absorp- 
tion of  the  products  of  gastric  fermentation,  lavage 
before  going  to  bed  is  often  followed  by  marked  relief 
As  a  rule  the  best  hour  of  the  day,  should  sleep  be  un- 
disturbed, is  before  breakfast,  when  as  much  nourish- 
ment has  been  extracted  from  the  ingesta  as  possible. 
If  sleep  is  not  affected  the  fermentative  processes  are 
seldom  very  active  or  deleterious.  After  lavage,  some 
light  nourishment  should  at  once  be  taken  ;  liquids 
such  as  milk  and  potash  water,  or  bovril,  may  be  ad- 
ministered by  the  tube  before  withdrawal. 

If  lavage  is  practised  more  than  once  daily,  care 
must  be  taken  to  avoid  emptying  the  stomach  shortly 
after  each  meal.  Absorption,  in  most  of  the  cases  in 
which  lavage  is  beneficial,  is  slow,  and  the  regular 
removal  of  the  food  within  four  or  five  hours  of  its 


124       TREATMENT  BY  ELECTRICITY 

ingestion  practically  starves  the  patient.  Patients, 
hov/ever,  with  largely  dilated  stomachs,  due  to 
non-malignant  contraction  and  narrowing  of  the 
pyloric  orifice,  in  whom  little  or  nothing  can  -pass 
into  the  duodenum,  may  derive  much  relief  from  the 
artificial  removal  of  the  contents  before  each  meal. 

Lavage  is  contra-indicated  under  the  same  condi- 
tions noted  already  as  rendering  the  passage  of  the 
tube  inadvisable  or  dangerous.  When. the  tube  is 
easily  tolerated,  however,  lavage  may  be  practised  in 
conditions  which  forbid  the  use  of  the  stomach  tube, 
because  its  passage  occasions  violent  retching  and  dis- 
comfort. 

Treatment  by  Electricity. 

The  application  of  the  Faradic  and  Galvanic  currents 
is  often  of  service  in  the  treatment  of  some  forms  of 
dyspepsia. 

The  application  may  be  made  in  two  ways  :— 

1.  Both  electrodes  may  be  placed  upon  the  skin. 

2.  One   electrode    may  be   introduced    into   the 
stomach,  the  other  applied  to  the  skin. 

Apparatus  Required. 

I.  The  Battery. — The  best  form  of  cell  for  generat- 
ing the  current  is  the  Leclanche-Barbier,  as  recom- 
mended by  Herschell.  In  this  cell  the  outer  case 
is  made  up  of  zinc,  a  cone  of  carbon  occupies  the 
centre,  and  the  space  between  is  filled  with  a  jelly 
containing  chloride  of  ammonium.  The  carbon  cone 
is  hollow,  and  when  the  jelly  becomes  too  dry,  it  may 


TREATMENT    BY    ELECTRICITY  1 25 

be  moistened    by  the   introduction    of  a    solution    of 
chloride  of  ammonium  into  its  cavity. 

2.  A  Dial  Collector,  or  a  Rheostat. — The  first  should 
be  so  constructed  that  the  cells  used  can  be  taken 
from  any  part  of  the  series.  The  rheostat,  by  diminish- 
ing the  resistance,  allows  the  gradual  application  of  an 
increased  current  to  the  part  treated. 

3.  A  Galvanometer. — The  best  form  for  use  is  what 
is  known  as  a  '  dead-beat '  galvanometer,  in  which  the 
needle  moves  back  at  once  to  its  original  position 
without  oscillation. 

4.  De  Watteville  s  Key. — This  is  necessary  to  allow 
of  a  reversal  of  the  current,  or  a  change  in  the  form  of 
electricity. 

,  5.  A    Faradic   Coil. — With  a  key   for    turning   the 
current  on,  and  two  or  three  cells  for  generating  it. 

6.  Conducting  Cords  {Rheophores)  and  Electrodes. — 
The  conducting  cords  should  be  of  considerable  length. 
Many  forms  of  electrodes  have  been  recommended, 
both  for  external  and  internal  use. 


I.  External  Electrodes. 

(a^  For  use  where  both  electrodes  are  placed  on  the 
skin.— For  the  purpose  two  large  flat  electrodes  are 
employed.  The  one  is  applied  to  the  anterior  . 
abdominal  wall  over  the  gastric  region,  the  other 
placed  on  the  side  close  by.  Or,  if  it  is  desired  to 
apply  the  current  to  the  sympathetic  in  the  cervical 
region,  the  electrode  placed  on  the  skin  over  it  should 
be  smaller — i.e.,  two  and  a  half  by  one  and  a  quarter 
inches. 

Ziemssen  got  good  results  by  using  electrodes  of 


126  TREATMENT    BY    ELECTRICITY 

about  500  to  600  square  centimetres  in  area  (80  to 
100  square  inches),  a  strong  galvanic  current,  and 
brief  faradisation  of  the  skin  of  the  abdomen,  chest, 
and  back.  The  surface  of  the  electrodes  for  applica- 
tion to  the  skin  should  be  covered  with  flannel, 
spongio-piline,.or  better,  a  sponge  may  be  used.  A 
serviceable  electrode  consists  of  a  sponge  about  five 
inches  in  diameter  carried  on  in  a  wooden  base 
(Herschell)  ;  another,  of  a  sponge  about  three  inches 
.across,  in  a  vulcanite  cup. 

The  advantages  which  accrue  from  the  use  of  a 
sponge  electrode  consist  in  the  greater  ease  with 
which  it  can  be  cleaned,  and  in  the  power  it  affords  the 
operator  of  gradually  increasing  the  strength  of  the 
current  by  increasing  the  pressure  whilst  applying  it. 

{b.)  For  7ise  when  one  electrode  only  is  applied  to  the 
skin. — In  this  case  the  best  results  are  obtained  with 
large  electrodes.  A  flat  electrode,  six  inches  by  four, 
covered  with  spongio-piline,  answers  very  well.  It  is 
placed  over  the  epigastrium. 

2.  Electrodes  for  Direct  Use  in  the 
Stomach. 

,  (<^.)  The  simplest  form  of  electrode  for  use  in  the 
\stomach  consists  simply  of  an  ordinary  red-rubber 
stomach  tube  of  large  diameter,  perforated  with 
several  small  openings  close  to  the  end;  if  it  has 
a  lateral  eye,  this  should  be  situated  nearer  the 
extremity  than  in  the  ordinary  tube.  A  flexible 
metallic  rod  is  also  provided,  with  a  rounded  bulb  at 
the  lower  end,  very  similar  to  that  of  an  oesophageal 
bougie.     This  bulb  fills  up  the  lumen   of  the   tube 


TREATMENT    BY    ELECTRICITY  12/ 

completely  when  passed  down  it,  and  is  of  sufficient 
length  to  extend  from  the  tip  of  the  tube  up  to  and 
beyond  the  terminal  eyes.  The  rubber  tube  is  passed 
into  the  stomach  in  the  usual  wa}'.  If  it  is  made 
with  one  lateral  eye  of  the  ordinary  size  it  can 
be  used  to  wash  out  the  organ  and  to  introduce 
the  water  beforehand  j  the  metallic  rod  is  now  intro- 
duced down  the  lumen.  During  the  progress  of  the 
rod  the  patient  should  throw  back  his  head  as  far  as 
possible  to  straighten  the  curve  of  descent,  as, 
although  flexible,  a  metallic  rod  exerts  considerable 
pressure  outwards  at  the  convexity  of  its  curve,  thus 
causing  increased  pharyngeal  discomfort. 

{b.)  EinJiorn's  Deglntabk  Stomach  Electrode. — Ein- 
horn  of  Xew  York  has  devised  a  novel  form  of 
electrode,  in  the  shape  of  an  ovoid  hard-rubber 
capsule  about  the  size  of  an  almond.  The  capsule  is 
perforated  with  numerous  e}-elets  (Fig.  VII.)  and  con- 
tains a  small  button  electrode.  The  electrode  is  con- 
nected with  a  delicate  wire  covered  with  indiarubber, 
which  is  continuous  with  the  rubber  of  the  capsule. 
To  use  it,  the  patient  drinks  a  glass  of  water,  when 
fasting,  or  after  a  light  meal,  then  opening  his  mouth 
widely  the  capsule  is  placed  far  back  on  the  root  of  the 
tongue.  Taking  a  mouthful  of  water  and  swallowing, 
the  capsule  passes  easily  over  the  pharynx,  and  iinds 
its  way  into  the  stomach.  A  mark  on  the  rubber 
cord,  1 6  inches  (40  cm.)  from  the  capsule,  serves  to 
denote  when  the  electrode  has  reached  the  stomach — 
i.e.,  when  the  mark  comes  to  the  teeth. 

Once  in  the  stomach  the  connecting  wire  is  joined 
to  the  negative  pole  of  the  batter}-. 

If  on  withdrawal  of  the  capsule  any  resistance  be 


128  TREATMENT    BY    ELECTRICITY 

felt  at  the  cardiac  orifice  of  the  stomach,  no  force 
should  be  used.  Let  the  patient  swallow  once  or 
twice,  and  at  the  moment  when  the  larynx  rises 
during  deglutition,  slight  traction  will  serve  to 
withdraw  the  electrode. 

(c.)  Ewald  has  modified  Einhorn's  electrode,  and  in- 
vented a  .very  useful  instrument.  It  consists  of  a 
hollow  sound  of  rubber,  about  the  size  of  a  Nekton's 
catheter  No.  13,  through  which  the  wire  is  dra^vn. 
The  wire  terminates  in  an  electrode  very  similar  to 
that  suggested  by  Einhorn,  but  the  greater  rigidity  of 
the  connecting  tube  renders  it  possible  to  exert  some 
force  on  the  electrode  should  its  passage  down  be 
arrested  in  the  oesophagus,  as  sometimes  occurs  dur- 
ing the  use  of  Einhorn's  instrument. 

Details   of  the  Application. 

External  Electrisation. 

I.  Galvanisation. — The  electrodes  used  should  be 
thoroughly  soaked  with  warm  salt  and  water,  and  it 
is  as  well  to  wash  the  skin  with  soap  and  water 
beforehand. 

The  connecting  wire  from  the  negative  pole  of  the 
battery  is  attached  to  the  electrode  placed  over  the 
epigastrium  in  the  direction  of  the  long  axis  of  the 
stomach.  This  electrode  should  be  as  large  as  pos- 
sible. The  positive  and  smaller  electrode  is  applied 
on  the  left  side  of  the  abdomen,  close  to  the  first.  If 
the  patient  be  a  male  he  can  hold  the  larger  electrode 
in  position  himself,  and  a  sponge  electrode  may  be 
used.     In  female   patients   the   dress   need   only   be 


TREATMENT  BY  ELECTRICITV       I  29 

loosened,  and  an  electrode  covered  with  flannel  used. 
The  pressure  of  the  clothes  suffices  to  keep  it  in 
position. 

The  sitting  should  not  last  longer  than  from  five  to 
ten  minutes,  and  the  current  used  should  be  strong 
enough  to  cause  marked  contractions  of  the  abdominal 
muscles,  apart  from  the  causation  of  pain. 

The  positive  electrode  may  be  placed  on  other 
parts  of  the  body  if  desired  ;  over  the  sympathetic  in 
the  neck,  as  Baradini  *  has  recommended  ;  or  over 
the  spinal  cord,  when  the  electrode  may  be  slowly 
passed  up  and  down  the  spine,  or  it  may  be  fixed  in 
one  position. 

2.  Faradisation.  —  In  applying  this  form  of  elec- 
tricity two  small  electrodes  may  be  employed,  placed 
one  or  two  inches  apart  over  the  stomach  region  ; 
or  a  large  flat  electrode  may  be  placed  over  the 
stomach,  and  another  on  some  insensitive  part,  as 
over  the  buttocks.  The  application  may  last  ten 
minutes,  and  the  current  used  should  be  strong  enough 
to  cause  muscular  contractions.  It  is  often  advisable, 
especially  in  neurasthenic  cases,  to  apply  the  current 
to  the  spinal  region.  The  smaller  electrode  should 
then  be  slowly  passed  up  and  down  the  spine,  and 
especial  attention  paid  to  the  left  side  in  the  cervical 
region,  to  stimulate  the  left  pneumogastric  nerve 
which  chiefly  goes  to  the  stomach. 

The  electric  brush  can  be  used  if  a  more  stimulat- 
ing effect  is  desired,  when  the  current  should  be  just 
strong  enough  to  produce  sparks  betv\-een  the  brush 
and  the  skin.  The  skin  must  be  dried  thoroughly 
beforehand. 

*  Journ.  de  la  Soc.  Scz'ent.,  1891,  No.  x.,  p.  97- 

I 


130  treatment  by  electricity 

Internal  Electrisation. 

As  noted  above,  the  application  of  the  electric 
current  directly  to  the  stomach  should  only  be  under- 
taken after  fasting,  or  after  washing  out  the  organ. 
To  prevent  any  direct  contact  between  the  mucous 
membrane  and  the  actual  electrode,  the  stomach 
must  be  partially  filled  with  water.  If  the  case  be 
one  of  great  gastric  dilatation,  a  considerable  quantity 
of  water  may  be  required,  as  the  current  only  affects 
those  parts  of  the  viscus  in  contact  with  the  water. 

Galvanisation. — The  large  electrode  placed  on  the 
abdominal  wall  is  connected  with  the  positive  pole, 
and  should  be  moved  about  over  the  stomach  region. 
The  current  used  is  of  a  strength  equal  to  from  15 
to  20  milliamperes,  and  should  not  be  continued 
for  more  than  eight  minutes  at  each  sitting. 

Faradisation. — The  external  electrode  should  be 
kept  in  motion  over  the  skin  of  the  gastric  region, 
and  current  used  as  rapidly  interrupted  as  possible. 
In  this  way  the  application  is  rendered  much 
smoother.  As  before,  the  strength  of  current  em- 
ployed must  be  such  as  to  cause  muscular  contractions 
without  giving  rise  to  pain. 

Indications  for  the  Use  of  Electricity. 

In  atony  of  the  stomach  walls. — Faradisation,  both 
internal  and  external,  acts  most  beneficially.  If  the 
atony  be  an  accompaniment  of  neurasthenia,  the 
continuous  current  should  also  be  used. 

In  dilatation  of  the  stomach. — The  evidences  of  its 
effects  here  are  very  conflicting,  but  it  acts  beneficially 
in  cases  of  moderate  enlargement,  especially  if  associ- 
ated with  nervous  symptoms. 


TREATMENT  BY  ELECTRICITY       I3I 

Gastralgia. — For  this  it  may  be  used  externally 
first,  and,  if  necessary,  directly  to  the  stomach  wall 
afterwards. 

Hypochlorhydria. — The  internal  application  of  the 
interrupted  current  acts  better  in  such  cases  than  the 
use  of  the  galvanic  stream,  or  external  electrisation. 

Illumination  of  the  Stomach. 

Einhorn  has  invented  an  instrument  for  the  direct 
illumination  of  the  stomach  cavity,  by  means  of  which 
a  slightly  luminous  area,  corresponding  to  the  portion 
of  the  stomach  uncovered  by  other  tissues  save  the 
abdominal  wall,  can  be  seen  on  the  anterior  wall 
of  the  abdomen  in  a  darkened  room  (Fig.  VIII.). 

The  Gastrodiaphanoscope,  or,  as  it  has  been  more 
lately  christened,  the  Gastrodiaphane,  consists  of  a 
soft  rubber  tube,  such  as  is  usually  employed  in  lavage, 
bearing  at  the  end  an  Edison  lamp  of  hard  glass. 
The  electric  lamp  is  connected  with  a  battery  by  two 
wires  enclosed  in  the  tube.  The  lamp  is  connected 
with  the"  stomach  tube  by  means  of  a  metal  mounting. 
The  lamp  and  the  mounting  are  of  the  same  diameter 
as  the  tube.  Before  using  the  instrument  on  the 
human  subject,  it  is  as  well  to  attach  it  to  a  battery, 
and,  immersing  the  lamp  in  water,  to  test  its  stability 
by  passing  through  it  a  somewhat  higher  current  than 
is  used  when  in  the  stomach.  The  patient  should 
drink  one  or  two  full  tumblers  of  water  beforehand. 
To  avoid  all  untoward  consequences,  the  stomach 
should  be  almost  full  of  water.  When  the  current  is 
turned  on  in  a  darkened  room,  a  feebly-illuminated 
area  of  the  abdominal  wall  may  be  seen.  This 
area,  in  healthy  people,  corresponds  to  the  portion  of 


132  OTHER    INSTRUMENTS 

the  stomach  uncovered  save  by  the  abdominal  walls, 
and  is  situated  below,  and  a  little  to  the  left  of  the 
xiphi-sternum.  In  dilatation  of  that  organ,  or  in 
gastroptosis,  the  illuminated  area  takes  a  lower 
position,  and  a  more  rectangular  shape.  In  some 
cases,  under  favourable  circumstances- — that  is,  when 
the  abdominal  walls  are  thinly  clothed — thickenings 
and  tumours  of  the  gastric  walls  may  be  shown  by  a 
local  decrease  in  translucency,  or  by  an  altered  form 
of  the  luminous  area.     (Figs.  IX-XI.) 

It  is  evident  that  this  instrument  can  only  prove 
of  value  under  favourable  conditions.  If  the  patient 
be  stout,  little  or  nothing  can  be  seen,  while  a  pyloric 
tumour  is  only  perceptible  when  the  end  of  the  tube 
is  able  to  be  introduced  below  and  behind  it,  as  in  a 
dilated  stomach,  where  the  greater  curvature  hangs 
down  to  a  lower  level  than  the  tumour. 

Other  Instruments. 

Turck's  Gyroniele. — Fenton  B.  Turck  *  describes  in 
this  journal  an  instrument  which  he  had  invented  some 
time  previously.  Designed  to  indicate  the  position, 
shape,  and  size  of  the  stomach,  it  is  called  the 
'  Gyromele,'  and  consists  of  a  tube  containing  a 
cable,  with  a  sponge  at  its  extremity.  An  apparatus 
for  producing  rapid  rotation  of  the  cable  and  the 
sponge  attached  to  its  lower  extremity  is  attached 
to  the  outer  end.  After  introduction  of  the  tube  into 
the  stomach,  if  the  cable  be  passed  onwards  down  it,, 
the  rotating  sponge  glides  over  the  mucous  membrane 
of  the  larger  curvature,  turns  up  towards  the  pylorus, 
and  then  along  the  smaller  curvature.     The  positions 

'^.New  York  Med.  Jourti.^  Feb.  22,  1896. 


Fig.  8. — Einhorn's  Gastro-Diaphanoscope. 
(Seepage  131.) 


Fig.  9. — Normal  transillumined 
area.    (See  page  132.) 


Fig.  10. — Area  transillumined  in 
Dilatation.     (See  page  132.) 


Fig.  11. — Area  transillumined  In 
Gastroptosis.    (See  page  132.) 


OTHER    INSTRUMENTS  1 33 

of  the  cable  and  sponge  can  be  easily  felt  through 
the  abdominal  wall  if  rotated  rapidly.  When  cables  of 
different  flexibility  are  used,  the  distensibility  of  the 
stomach  walls  can  be  gauged.  Thus  a  very  flexible 
cable  is  used  first  and  pushed  in  until  it  meets  with 
resistance  at  the  lesser  curvature.  The  length  intro- 
duced is  noted.  The  revolving  sponge  is  at  the  same 
time  palpated  through  the  abdominal  wall,  and  the 
depth  of  descent  ascertained.  A  stiffer  cable  is  now 
used  in  the  same  way,  and  the  difference  between  the 
length  of  the  stiff  cable  which  has  been  introduced 
before  the  resistance  is  felt  and  that  of  the  more 
flexible  one,  serves  to  indicate  the  power  of  distension 
of  the  walls.     (Fig.  XII.) 

The  movements  of  the  gyromele  can  sometimes  be 
felt  behind  the  liver,  and  in  thin  subjects  the  rotatory 
movements  of  the  sponge  can  even  be  seen  through 
the  abdominal  wall.  If  the  stomach  be  prolapsed  the 
sponge  can  be  felt  as  it  follows  the  lesser  curvature 
below  the  margin  of  the  liver.  The  revolving  sponge 
acts  also  as  a  curative  agent  by  removing  any  mucus 
adhering  to  the  mucous  membrane,  can  be  used  for 
the  direct  application  of  therapeutic  substances,  or 
as  an  electrode  capable  of  applying  the  electric 
current  topically  to  various  parts  of  the  organ.  The 
vibratory  effects  arising  from  its  use  are  often  of 
service  in  cases  of  dilated  stomach ;  the  motor  power 
of  the  stomach  is  stimulated,  and  the  mucous 
membrane  becomes  more  vascular  from  its  rubbing 
or  massage-like  action. 

Boas  *  uses  a  modified  gyromele  in  which  the 
sponge  is  attached  to  the  end  of  a  soft  solid  bougie, 

*  Cenlralbl.  f.  iimere  Med.^  Feb.  8,  1896. 


134  MASSAGE 

and   the   apparatus   rotated    as    in    Turck's    instru- 
ment. 

Massage   of  the  Stomach. 

Little  need  be  said  here  about  massage  for  stomach 
diseases.  It  is  especially  indicated  in  cases  of  dilated 
stomach,  nervous  dyspepsia,  and,  indeed,  all  cases 
with  delayed  motility.  It  may  with  advantage  be 
combined  with  electrical  treatment. 

At  first  the  patient  should  be  placed  on  his  back 
with,  his  legs  bent  and  his  head  slightly  raised,  two 
or  three  hours  after  a  meal.  Massage  of  the 
abdominal  wall  over  the  stomach  is  then  begun, 
from  the  cardia  towards  the  pylorus.  The  patient 
is  then  placed  on  his  right  side  and  petrissage  per- 
formed from  over  the  pylorus  towards  the  cardia. 
The  sitting  should  last  about  fifteen  minutes. 

It  has  been  found  to  shorten  the  duration  of 
emptying  of  the  stomach — by  an  hour  in  some  cases. 

In  cases  of  moderate  stagnation  of  the  stomach 
contents,  good  may  often  accrue  if  the  patient  be 
told  to  lie  on  his  right  side  at  night,  and  to  person- 
ally rub  the  epigastric  region  from  the  left  side  up- 
wards and  to  the  right. 


CHAPTER  X. 

THE   MECHANICAL   METHODS   USED    IN   YOUNG 
CHILDREN. 

By  JOHN  THOMSON,  M.D.,  F.R.C.P.  Ed. 

Gavage — by  the  Nose — by  the  Mouth — Indications  ;  Lavage — Method 
— Indications. 

The  mechanical  treatment  of  the  stomach  in  young 
children  may  be  considered  under  two  heads — 
(i)  Forced  Feeding,  or  Gavage ;  (2)  Stomach  Washing, 
or  Lavage.  Both  these  measures  are  simple  of 
application  and  of  great  value  in  suitable  cases  as 
therapeutic  measures.  At  present,  however,  the  use  of 
the  latter  as  an  aid  to  diagnosis  is  limited  to  excep- 
tional cases. 

1.  Forced  Feeding,  or  Gavage. 

MetJiods  and  Appai'-atus. — There  are  a  great  many 
devices  by  the  use  of  which  fluid  food  and  medicine 
can  be  introduced  into  the  stomach  of  a  child  who  is 
unable  or  unwilling  to  swallow  them  in  the  ordinary 
way.  In  some  of  these  the  nose  is  used  as  the  way 
of  access  to  the  pharynx,  while  in  others  the  food  is 
passed  through  the  mouth. 

{a)  Nasal     Feeding. — Of    this    there    are    several 


136  GAVAGE 

methods.  The  first  of  these,  and  the  simplest, 
consists  in  pouring  a  bland  form  of  liquid  nourish- 
ment into  one  nostril,  through  which  it  rapidly  finds 
its  way  into  the  pharynx  and  is  inevitably  swallowed. 
In  doing  this,  the  child  should  be  kept  lying  on  his 
back,  and  his  head  must  be  held  steady.  The  food 
given  must,  of  course,  be  quite  unirritating  in  char- 
acter {e.g.  milk).  It  is  poured  into  the  nose  by  means 
of  a  glass  or  rubber  ear-syringe,  over  the  nozzle  of 
which  a  short  piece  of  indiarubber  tubing  has  been 
fitted ;  or  a  special  spoon  may  be  used,  the  sides  of 
which  are  folded  over  near  the  point,  so  as  to  form  a 
kind  of  narrow  spout.  The  process  of  feeding  must 
take  place  slowly,  and  regular  pauses  must  be  made 
to  allow  of  swallowing. 

,  The  second  method  resembles  the  first  in  all  respects, 
except  that  the  rubber  tube  attached  to  the  nozzle  of 
the  syringe  is  long  enough  in  this  case  to  reach 
through  the  nasal  cavity  to  the  nasopharynx.  It  is 
used  when  the  fluid  to  be  given  is  of  such  a  nature 
as  to  irritate  the  delicate  mucous  membrane  of  the 
nose.  When  the  fluid  is  bland,  the  first  method 
is  preferable,  as  the  pressure  of  the  rubber  tube 
is  itself  a  cause  of  irritation. 

The  third  method  consists  in  the  passage  of  a 
tube  through  the  nose,  pharynx,  and  gullet  into  the 
stomach.  For  this  a  soft  rubber  catheter.  No.  12  or 
No.  1 3  (French),  is  suitable.  It  is  thoroughly  oiled  and 
passed  backwards  through  the  nose  into  the  pharynx. 
This  may  be  done  with  the  patient  lying  on  his  back; 
but  often,  in  older  children  especially,  the  sitting 
posture  is  preferable  When  the  end  of  the  catheter 
reaches    the  pharynx,   there   is  often    retching,    and 


GAVAGE  137 

some  resistance  is  felt.  The  patient's  head  should 
then  be  inclined  slightly  forward  and  the  tube  pushed 
gently  on.  When  it  gains  the  oesophagus  it  generally 
ceases  to  irritate  the  pharynx ;  and,  soon  after,  the 
passage  of  gas  and  liquid  from  its  upper  end  indicates 
that  it  has  reached  the  stomach. 

The  catheter  occasionally  passes  into  the  larynx  ; 
this  is  not  common,  and  its  occurrence  is  at  once 
announced  by  the  onset  of  cough  and  dyspnoea. 
Much  more  frequently  it  finds  its  way  forward  into 
the  mouth,  and  this  is  very  apt  to  happen  if  there  is 
much  coughing  or  retching  while  the  end  of  the 
catheter  is  passing  the  pharynx.  When  the  catheter 
has  reached  the  stomach  and  the  retching  has 
stopped,  the  food  is  introduced  into  it  by  a  funnel  or 
syringe. 

Probably  the  best  funnel  for  the  purpose  is  a  glass 
syringe  of  moderate  size  from  which  the  piston  has 
been  removed.  It  fits  into  the  catheter  easily,  and, 
should  any  obstruction  occur  in  the  process  of 
feeding,  the  piston  can  be  replaced  and  used  to 
clear  it  away.  While  the  catheter  is  being  with- 
drawn, its  end  must  be  tightly  compressed,  lest  the 
few  drops  remaining  in  it  should  get  into  the  larynx 
in  passing. 

{b)  Forced  Feeding  by  the  Month. — This  is  generally 
carried  out  by  the  passage  of  an  oesophageal  tube  into 
the  stomach.  The  apparatus  required  is  the  same  as 
that  used  for  stomach-washing,  namely  :  a  soft  rubber 
catheter,  connected  by  an  inch  or  two  of  glass  tube, 
and  a  foot  and  a  half  of  rubber  tubing  with  a  vulcanite 
funnel,  large  enough  to  hold  from  3  to  6  oz.  The 
catheter  should  have  one  or  two  extra  eyes,  and  its 


138  GAVAGE 

size  varies  with  the  size  of  the  child  from  Xo.  14  to 
No.  18  (French). 

The  child  is  placed  flat  on  his  back,  his  head  being 
held  steady  by  an  assistant.  1  he  left  forefinger  is  then 
placed  lightly  on  the  tongue  to  depress  it,  while  with 
the  right  hand  the  catheter,  well  oiled,  is  passed 
down  the  phar3'nx  for  8  or  10  inches.  The  stomach 
being  reached,  the  funnel  is  raised  for  a  few  moments 
to  allow  the  escape  of  gas.  The  food  is  now  poured 
into  the  funnel  and  rapidly  finds  its  way  into  the 
stomach.  When  the  funnel  empties,  the  tube  is 
tightly  compressed,  and  rapidly,  but  gently,  with- 
drawn. If  the  withdrawal  of  the  catheter  is  done 
slowly  or  carelessly,  it  is  apt  to  excite  vomiting.  In 
infants  who  have  no  teeth,  or  only  one  or  two,  no  gag 
is  required.  In  older  children  some  sort  of  gag  is 
necessar}^,  as  there  is  otherwise  danger  of  the  tube 
being  bitten.  In  them,  however,  the  process  is 
much  more  difficult  than  in  babies,  and  not  nearh- 
so  generally  useful. 

A  simpler  form  of  forced  feeding  (first  recom- 
mended by  ]\Ir  Scott  Battams)  often  proves  of 
great  value.  For  this  all  that  is  necessary-  is  an 
ordinary  glass  or  ball  s}-ringe,  to  the  nozzle  of  which 
four  inches  of  rubber  tube  are  attached.  The  child, 
who  is  refusing  food,  or  who  for  some  reason  ought  not 
to  be  allowed  to  suck  in  the  ordinar}'  way,  is  laid  on 
his  back,  the  tube  is  passed  towards  the  back  of  the 
mouth,  and  the  liquid  is  gently  injected.  In  older 
children  who  close  their  teeth,  the  tube  may  easily  be 
passed  backwards  inside  the  cheek,  and  the  liquid 
thus  readily  reaches  the  pharynx. 


GAVAGE  139 

Indications  for  Forced  Feeding. 

In  children  these  are  many  and  various,  and  the 
method  chosen  must  depend  on  the  requirements  of 
the  case  in  hand  and  on  the  nature  of  the  fluid  to  be 
administered.  The  following  are  perhaps  the  most 
important  conditions  in  which  forced  feeding  proves 
valuable. 

1.  In  the  rearing  of  preniaUire  infants,  periodic 
feeding,  either  through  the  nose  with  a  spoon  or  by 
means  of  a  catheter  passed  through  the  mouth,  has 
been  found  of  great  use.  It  was  first  made  use  of  by 
Prof  Tarnier  of  Paris. 

2.  Similarly,  in  young  infants  and  others  who  are 
so  weak  that  the  effort  of  sucking  and  swallowing 
exhausts  them,  great  benefit  may  be  got  from  forced 
feeding  either  through  the  nose,  or  preferably  through 
the  mouth  by  Mr  Scott  Battams'  method. 

3.  In  some  cases  of  prostration  {e.g.  in  typhoid) 
there  is  obstinate  refusal  of  all  food  and  medicine  to  an 
extent  which  seriously  endangers  life.  These  cases 
may  be  effectually  treated  by  one  of  the  methods 
of  nasal  feeding  or  by  the  syringe  and  short  tube. 

4.  The  same  methods  are  very  serviceable  when 
swallowing  is  interfered  with  by  pain  due  to  ulce^'ation 
of  the  mouth  or  throat. 

5.  A  few  years  ago,  Dr  Kerley  drew  attention  to  the 
fact  that  regular  forced  feeding  by  means  of  an  oeso- 
phageal tube  passed  into  the  stomach  was  extremely 
useful  in  persistent  vomiting  in  infants.  Babies  who 
are  not  able  to  retain  even  a  teaspoonful  of  fluid 
swallowed  in  the  ordinary  way,  can  usually  retain 
a    much    larger    amount    of   nourishment    if    it    is 


I4Q  LAVAGE    IN    YOUNG    CHILDREN 

poured  into  the  stomach  through  a  catheter.  The 
explanation  of  this  remarkable  fact  is  obscure, 
but  of  the  value  of  its  application  in  practice  there 
can  be  no  doubt  whatever. 

6.  When  in  cerebral  cases,  in  cases  of  narxotic 
poisoning,  and  in  convulsive  conditions  such  as  tetanus, 
the  process  of  swallowing  is  interfered  with,  life  may 
be  prolonged  and  sometimes  saved  by  forced  feeding 
with  a  tube  either  through  the  nose  or  mouth.  In  the 
same  way,  in  cases  oi  diphtheritic  paralysis  affecting  the 
pharynx,  feeding  through  a  tube  is  of  the  greatest 
value  in  keeping  the  patient  alive  until  the  part 
recovers  its  function. 

2.  Stomach  Washing,    or  Lavage. 

Methods  and  Apparatus. — A  soft  rubber  catheter 
connected  with  a  vulcanite  funnel  by  i8  inches  of 
tubing,  such  as  is  used  for  ordinary  gavage,  consti- 
tutes the  best  apparatus  for  stomach  washing.  The 
catheter  used  should  be  the  largest  that  can  be  easily 
passed,  and  should  have  two  or  three  eyes.  Plain  luke- 
warm water  is  probably  as  good  as  any  other  fluid. 

The  child  is  made  to  sit  or  lie  on  his  mother's  knee 
with  his  face  looking  towards  her  left  side,  and  with 
his  clothes  and  hers  duly  protected  by  a  mackintosh 
sheet.  A  slight  pressure  on  the  chin  generally  makes 
him  open  his  mouth,  and  the  catheter  is  then  passed 
gently  backward  over  the  tongue,  and  down  the 
oesophagus,  as  already  described  in  speaking  of 
gavage.  When  the  stomach  is  reached  and  the  funnel 
has  been  momentarily  raised  to  allow  any  gas  present 
there  to  escape,  the  water  is  poured  into  it  from  an 
ordinary  jug.     Jn  doing  this    one    must    be    careful, 


LAVAGE    IN    YOUNG    CHILDREN  14[ 

especially  in  weakly  children,  not  to  over-distend  the 
stomach  by  running  in  too  much  water  at  a  time,  or 
by  holding  the  funnel  too  high.  When  a  sufficient 
amount  of  water  has  been  introduced,  the  funnel  is 
lowered,  and  the  contents  of  the  stomach  rapidly  fill  it 
by  syphon  action,  and  are  allowed  to  run  away.  The 
tube  is  then  pinched  to  prevent  the  entrance  of  air, 
the  funnel  raised  again  and  refilled  with  water,  and 
the  process  repeated.  The  washing -out  should  be 
continued  until  fragments  of  curd,  etc.,  cease  to  be 
found  in  the  returning  fluid. 

Indications  for  Stomach   Washing. 

1.  In  so-called  ' sinmner  diarrhcea'  or  ' iniik  infec- 
tion'^ stomach  washing,  combined  with  irrigation  of 
the  lower  bowel,  constitutes  the  most  rational  and 
successful  preliminary  treatment.  When  first  intro- 
duced it  was  supposed  that  it  should  only  be  em- 
ployed in  those  children  who  were  not  very  weak. 
It  is  now  recognised  that  the  weaker  the  infant  the 
more  important  is  it  to  wash  out  his  stomach 
without  delay,  because  the  very  active  poisons  to 
which  the  most  alarming  symptoms  are  due  can  be 
partially  removed  in  this  way.  The  process  itself  is 
practically  without  danger  if  carefully  carried  out. 

2.  In  all  forms  of  chronic  vomiting  of  gastric  origin 
in  children,  irrigation  of  the  stomach  may  be  useful  ; 
but  owing  to  the  practical  difficulties  met  with  in  its 
application  to  older  children,  its  use  is  mainly  confined 
to  babies.  In  a  great  many  cases  one  washing-out  is 
sufficient  to  initiate  improvement  in  the  symptoms  ; 
in  others,  the  process  may  have  to  be  repeated  daily 
for  several  days.     Not  infrequently  in  an   infant  who 


142  LAVAGE    IN    YOUNG    CHILDREN 

has  been  vomiting  several  times  a  day  for  weeks,  the 
symptom  will  cease  altogether  after  one  washing-out 
of  the  stomach.  This  may  be  the  case  even  when, 
owing  to  blocking  of  the  tube  with  curd,  the  irrigation 
has  been  so  imperfectly  carried  out  that  no  improve- 
ment is  expected.  Further,  it  has  been  found  that 
in  some  cases  mere  passing  of  the  stomach  tube, 
and  holding  it  in  position  for  a  minute  or  two,  seems 
to  exert  a  favourable  influence  and  stop  the  vomit- 
ing. The  writer  is  not  prepared  to  give  a  satisfactory 
explanation  of  this  curious  fact,  but  has  observed  it 
sufficiently  often  to  be  sure  that  the  improvement 
which  follows  in  these  cases  is  more  than  a  mere  coin- 
cidence. 

References. 

W.  Scott  Battams. — Lancet,  June  16  and  23,  1883. 

L.  Emmett  Holt. — New  Yorh  Med.  Record,  April  28,  1894. 

Chas.  G.  Kerley. — Archives  of  Pediatrics,  February  1892. 


CHAPTER  XL 
CLASSIFICATION  OF  GASTRIC  CONDITIONS. 

In  Relation    to  the  Variations   in  the  Acidities  —  To  the   Digestive 
Power — To  the  Duration  of  Digestion. 

Classification  of  Gastric  Conditions  in  relation  to 
the  Acidities  Present. 

I.  Acidity  Normal. 

Total  acidity  rising  to   0"2  5-0'35    per  cent. 
HCl. 
Free  hydrochloric  acid  present  up  to  O'l 

per  cent. 
Lactic  acid  in  traces  in  early  stages. 
Hydrochloric  acid  combined  with  proteids, 
increasing  until  third  stage,  0"2-0"3  per 
cent. 
No  free  HCl  in  first  stage,  unless  food  be 
free  of  proteids. 
In  health.     (Free  HCl  may  be  absent  during 
most  of  digestion,  if  the  food  taken  be  in 
large  bulk,  and  chiefly  of  proteids.) 
In    dyspeptic     symptoms,    and    haemorrhage, 
from  congestion  of  the  liver. 
Gastric  erosions  (occasionally). 
Carcinoma  of  the  cardiac  end,  or  of  the 
oesophagus. 


144  CLASSIFICATION    OF 

Sometimes  in  pyloric  carcinoma,  especially 
if  arising  after  previous  ulceration. 
In    many    cases    of    nervous    dyspepsia,   and 
dyspepsia    accompanying    anaemia,    or 
chlorosis. 

2.  Increased  Acidity.    Hyperacidity. 
(a.)  Due  to  an  ina^ease  of  Hydrochloric  Acid. 

Total  acidity  high,  0"3-0"45  per  cent. 
Free  hydrochloric  acid  in  excess,  0'2-0'3 

per  cent. 
Combined  hydrochloric  acid  normal. 
Free  HCl  appears  early. 
First    stage,   therefore,   short,   and    lactic 

acid  may  be  absent. 
After  a  large  proteid    meal  acidity  may 

rise  to  a  high  point. 
In  most  cases  of  gastric  ulcer,  and  of  gastric 

erosions. 
From  nervous  causes.    (Simple  hyperchlor- 

hydria.) 
In  some  cases  of  dilated  stomach. 

Hypersecretion  of  gastric  juice.     (Gastro- 

succorrhoea      continua      periodica,     vel 

chronica.     Reichmann's  disease;  Gastro- 

xynsis.     Rossbach's  disease.) 

{b.)  Due   to   an    increase  of   Organic   Acids   along 
with  lessejied  secretion  of  Hydrochloric  Acid. 

Total    acidity   high   but  variable,    0"3-0"8 

per  cent. 
Free  hydrochloric  acid  absent  or  only  in 

traces. 


GASTRIC    CONDITIONS  1 45 

Combined  HCl  generally  small  in  amount. 
First  stage  long,  lactic  acid  present. 
Lactic    and    volatile    fatty    acids    present 

during  later  stages. 
In  carcinoma  of  the  pylorus  and  adjacent  parts. 
Dilatation  of  the  stomach  ;  a,  with  pyloric 

obstruction  ;  b,  with  atony  of  walls. 
Atonic     dyspepsia,    and    chronic    gastric 

catarrh. 

In    some    cases    of   nervous  origin,   functional 

in  character. 
In  the  later  stages  of  chronic  ulcer,  owing  to- 

catarrh. 

3.  Hypoacidity. 

{a.)  Acidity  composed  cJiiefly  of  Hydrochloric  Acid. 
Total  acidity  low,  0-05-OI5  per  cent. 
Free  HCl  absent,  or  in  traces. 
Combined  HCl  small  in  amount,  o-05-o-i 

per  cent. 
All  stages  prolonged;  lactic  acid  present  ia 

first,  or  throughout. 
Traces  of  volatile  organic  acids  present. 
In  Hypochlorhydria,  without  fermentation. 

Acute    gastritis,    during    recovery,    or   at 

com  mencemen  t. 
Carcinoma   of  the  stomach,  without  bac- 
terial fermentation. 
Cirrhosis  ventriculi. 
In  moderate  dilatation  of  the  stomach  without 
fermentation. 
During  acute  or  chronic  febrile  and   sup- 
purative disorders. 

K 


J  46  CLASSIFICATION    OF 

((5.)  Acidity  due  to  Organic  Acids. 

In    extreme  cases  of  atrophy  of  the  mucous 
membrane  of  the  stomach  ;   in  cancer ; 
waxy   degeneration  ;    cirrhosis  ;    phleg- 
monous gastritis  ;  and  in  the  most  acute 
stages  of  febrile  diseases. 
Here   little   or    no    hydrochloric    acid    is 
secreted,  and    any  acidity  which   may 
be  present  is  due  to  the  organic  acids 
of  fermentation. 
From  the  table  given  above,  it  will  be  seen  that 
different  conditions  may  accompany  the  same  disease 
or  form  of  gastric  disorder.    The  variations  are  due  very 
largely  to  the  absence  or  presence  of  bacterial  fermen- 
tation, and,  in  a  less  degree,  to  the  existing  amount 
of  motility  possessed  by  the  stomach  walls. 

The  main  indications  consist  in  the  recognition  of 
the  amount  of  acidity  per  cent,  of  the  contents,  and 
the  determination  of  the  proportion  of  the  total 
acidity,  which  is  composed  of  hydrochloric  acid,  free 
or  combined.  The  nature  of  the  acids  producing  the 
acidity  not  due  to  hydrochloric  acid  affords  a  means 
of  recognising  the  nature  of  the  fermentative  process 
at  work  in  each  individual  case. 


Classification  in  Relation  to  Digestive  Po"wer. 

I.  Normal  or  Increased. 

Hydrochloric  acid  and  pepsin  may  be  increased. 
In  health. 

Gastric  ulcer,  and  gastric  erosions. 
Hyperchlorhydria. 


GASTRIC    CONDITIONS  1 47 

Many  cases  of  nervous  dyspepsia. 

Many  cases  of  cancer  of  oesophagus  and  cardiac 

end  of  stomach. 
Early  stages  of  catarrh. 
Early  stages  of  dilated  stomach  from  pyloric 

obstruction,  not  due  to  cancer. 
Hypersecretion. 

2.  Diminished. 

{a.)  Due  to  diminution  of  Hydrochloric  Acid. 
Cancer  of  pylorus  and  body,  earlier  stages. 
Chronic  catarrh,  early  stages. 
Severe  nervous  depression. 
Dilated  stomach. 

{b^  Both  Hydrochloric  Acid  and  Pepsin  diminished 
or  absent. 
Atrophy  of  mucous  membrane. 
Cancer  of  pylorus  and  wall  in  the  later  stages. 
Chronic  catarrh,  later  stages,  or  with  atrophy  of 

cells. 
Dilated  stomach  if  accompanied  by  catarrh. 
Acute  gastritis. 
Acute  fevers. 

Phthisis,  especially  towards  the  end. 
Cirrhosis  of  stomach. 
Speaking  generally,  in  functional  disorders  of  the 
stomach  there  is  seldom  any  marked  diminution  in 
the  secretion  of  pepsin,  although  the  amount  of 
hydrochloric  acid  may  be  much  lessened.  In  organic 
diseases  the  secretion  of  the  acid  is  affected  before 
that  of  the  pepsin,  but  the  latter  is  markedly  dimin- 
ished in  the  course  of  time. 


148      CLASSIFICATION    OF    GASTRIC    CONDITIONS 

Classification  in  Relation  to  the  Duration  of 
Digestion. 

1.  Normal. 

In  health. 

Megalogastria. 

Gastroptosis     without     dilatation     (may      be 

slightly  delayed). 
Gastric  ulcer  (may  be  shortened). 
Hyperchlorhydria    (may    be    shortened),   and 

hypersecretion. 
Gastric   erosions. 

2.  Lengthened. 

(a.)  From  decreased  motility. 
Dilated  stomach. 
Cancer  of  pylorus,  early  stages. 
Many  cases  of  nervous  dyspepsia. 

{b})  From  decreased  digestive  pozver. 
Atrophic  catarrh. 
Acute  gastritis. 
Cancer  of  walls  and  cardiac  end. 

{c.)  From  both  causes. 

Cancer  of  p}'lorus,  later  stages. 

Cirrhosis  of  stomach,  and  dilated  stomach  with 

catarrh. 
Many  cases  of  nervous  dyspepsia. 


CHAPTER  XII. 

THE  APPARATUS  AND  REAGENTS  REQUIRED  IN 
THE  EXAMINATION  OF  THE  STOMACH  CON- 
TENTS. 

Apparatus — Reagents — Tables  of  Standard  and  Deci-normal  Solutions 
— and  of  their  Equivalents. 

I.  Apparatus. 

(rt.)  For  the  usual  clinical  methods^  ivitJwut  special 

arrangements. 
Pipettes  to  hold  2,  5,  and  10  c.  c. 
Pipettes   are   usually    more    accurately  gradu- 
ated   and    satisfactory    than    the    ordinary 

measure-glasses. 
Measure    graduated    in    cubic    centimetres    to 

hold  50  or  100  c.  c. 
Two  or  three  urine  glasses. 
Iron  tripod  and  copper  gauze. 
Porcelain    evaporating    basins,   to    hold    20  to 

100  c.  c. 
Glass  beakers,  as   thin  as  possible,  to  hold  50, 

100,  and  1000  c.  c. 
Spirit  lamp,  or  Bunsen  burner. 
Glass  funnels,  3  and  6  inches  in  diameter. 
Test  tubes. 
Filter  papers. 
Glass  rods. 
Two  burettes  to  hold  50  c.  c,  graduated  in  5ths 

of  a  c.  c,  preferably  with  Shellbach's  band. 


150  APPARATUS 

Burette  stand,  double. 

Water  bath.  This  may  be  dispensed  with 
when  evaporating  fluids,  by  floating  the 
evaporating  dish  on  water  in  a  larger  basin  ; 
the  addition  of  some  common  salt  to  the 
water  in  the  outer  basin  hastens  the  process 
of  evaporation  as  its  boiling-point  is  raised. 

Half-a-dozen  fireproof  porcelain  crucibles,  to 
hold  20  c.  c. 

Microscope. 

(b.)    WheJi  special  analytical  facilities  are  accessible. 

In  addition  to  the  apparatus  detailed  above  : — 
Drjnng  chamber,  capable  of  being  kept  at  a 

constant  temperature  :  100°  or  110°  C. 
Separating  funnels. 
Sand-bath. 

Balance,  to  weigh  to  O'OOi  grm. 
Nickel,  or  platinumx  capsule. 
Carbonic  acid  apparatus. 
Bacteriological  requisites. 
Gas-volumetric     apparatus,     for     Mierzynski's 

method. 

2.  Solutions. 

Colour  Reagents. 
Alcoholic. 

1.  Phenol-phthalein,  2  to  4  per  cent, 

2.  Congo  red,  saturated. 

3.  Gunzburg's. 

Phloroglucin,  2  grm.,  gr.  xxx. 
Vanillin,  i  grm.,  gr.  xv. 
Absolute  alcohol,  30  c.c,  §j. 


APPARATUS  151 

4.  Boas'  reagent. 

Resorcin,  5  grm.,  gr.  Ixxv. 
White  sugar,  3  grm.,  gr.  xlv. 
Dilute  alcohol,  100  c.c,  §iijss. 

5.  Dimeth}4 -amido  -  azo  -  benzol,  0'5    per 

cent,  in  absolute  alcohol. 

6.  Cochineal. 

7.  TropKolin  OO,  i  in  30. 

Water}-. 

1.  Litmus.  (A  more  delicate  solution  of  this 
dye  is  that  termed  Azolitmine.  Powdered 
litmus  is  extracted  with  boiling  water,  eva- 
porated to  small  bulk,  acidified  with  acetic 
acid,  further  evaporated  almost  to  dryness, 
and  then  precipitated  with  85  per  cent,  alcohol. 
The  precipitate  is  collected,  dissolved  in 
water,  and  a  drop  of  chloroform  added  to  pre- 
serve it.  * 

2.  Benzo-purpurin.     Saturated  solution. 

3.  Mohr's  reagent. 

10  per  cent,  solution  of  potassium  sulpho- 

cyanide,  2  c.  c,  5ss. 
Solution    of    acetate    of     iron    (neutral),. 

0'5  c.  c,  nx  viij. 
Distilled  water,  20  c.  c,  5vj. 

4.  Perchloride    of    iron,    diluted    with    water 

until  almost  colourless. 

5.  Uffelmann's  reagent. 

A  few  drops  of  a  dilute  perchloride  of  iron 

solution. 
10  c.c.  of  2  to  5  per  cent,  carbolic  acid  (sijss). 

*  Pharmaceul.Jovni.,  vol.  Ivi,  March  7,  1896. 


152  SOLUTIONS 

6.  Sodium-alizarin-sulphonate,   i    per  cent,    in 
water. 

•Other  Solutions. 

1.  Lugol's  solution.     Iodine,  OT  grm.,  gr.  iss. 
Potassium  iodide,  02  grm.,  gr.  iij. 
Distilled  water,  200  c.  c,  §vj.,  3vj. 

2.  Deci-normal  solutions  of: — 
Caustic  soda,  4-0  grm.  in  lOOO  c.  c. 
Hydrochloric  acid,  3'65  grm.  in  lOOO  c.  c. 
Silver  nitrate,  lyo  grm.  in  lOOO  c.  c. 
Sulphocyanate    of    ammonium,    y6    grm.    in 

1000  c.  c. 

3.  Standard  Solutions. 

1.  Silver  nitrate,  29-075  grm.  in  lOOO  c.c,  i  c.c. 

001  grm.  NaCl,  or  0'Oo624  grm.  HCl. 

2.  Fehling's  solution,  loc.  c.  =0-05  grm.  glucose; 

and  sulphate  of  copper,  5  per  cent. 
Caustic  soda,  10  per  cent. 
Hydrochloric  acid. 
Acetic  acid. 
Nitric  acid. 
Trichloracetic  acid,  10  per  cent. 


Tables  of  Standard  Solutions  and  Equivalents 
used  in  the  Different  Methods. 

Normal  and  Deci-normal  Solutions. 

Normal  solutions  of  all  chemical  bodies  for  use  in 
analysis  contain  in  each  litre  the  exact  amount  of  each 
substance  in  grammes  which  corresponds  to  its 
molecular  weight. 


STANDARD    SOLUTIONS  I  53 

Deci-normal  solutions  are  formed  from  normal  solu- 
tions by  diluting  them  ten  times  with  distilled  water. 
.  Thus  sodium  hydrate  with  a  molecular  weight  of  40 
(23  +  I  +  16)  forms  a  normal  solution  in  water  when 
each  litre  contains  40  grammes,  or  a  deci-normal 
solution  when  the  litre  contains  4"0  grm.  A  known 
quantity  of  a  normal  solution  of  one  substance  is 
exactly  equivalent  to  the  same  quantity  of  a  normal 
solution  of  another. 

Thus  a  normal  solution  of  hydrochloric  acid 
contains  36-5  (i  +  35'5)  grm.  in  each  litre,  or  3-65 
grm.  in  the  same  quantity  of  its  deci-normal  solu- 
tion. 1000  c.  c.  of  either  solution  exactly  neutral- 
ises 1000  c.  c.  of  the  corresponding  solution  of  sodium 
hydrate. 

If  the  substance  used  be  dibasic  or  tribasic,  the 
amount  in  each  litre  of  its  normal  solution  is  only  one- 
half  or  one-third  of  its  molecular  weight. 

So  as  H2SO4  is  dibasic,  its  molecular  weight 
being  98  (2 -h  32  +  64) ,  only  49  grm.  are  contained  in 
each  1000  c.  c.  of  its  normal  solution.  Similarly, 
oxalic  acid  (126)  forms  a  normal  solution  with  63 
grm.  per  litre. 

Deci-normal  solutions  are  generally  employed  in 
the  analysis  of  gastric  contents. 

To  make  a  deci-normal  solution  of  sodium 
hydrate,  for  example,  a  little  more  than  40  grm.  of 
caustic  soda  should  be  dissolved  in  about  900  c.  c. 
of  distilled  water,  and  more  water  added  up  to  the 
1000  c.  c.  It  is  then  titrated  against  a  standard 
deci-normal  solution  of  an  acid,  of  which  a  small 
quantity  of  guaranteed  accuracy  can  be  obtained 
from    a   chemical    laboratory.       If    10    c.  c.    exactly 


154  STANDARD    SOLUTIONS 

neutralise  lO  c.  c.  of  the  acid  solution,  the  solution  is 
of  the  proper  strength.  If,  however,  gS  c.  c.  suffice  to 
turn  litmus  or  phenol-phthalein  blue  or  pink  respec- 
tively, 2  c.  c.  of  water  must  be  added  to  each  9-8  c.  c, 
or  20  c.  c.  to  each  980,  to  correct  the  error. 

When  more  of  the  soda  solution  than  of  the  acid  is 
used,  it  is  too  weak,  and  more  soda  must  be  added.  It 
is  easier  to  add  an  excess  at  once,  and  then  to  calcu- 
late the  additional  water  required,  than  to  try  to  add 
the  exact  amount  of  soda. 

The  solution  as  corrected  must  again  be  standard- 
ised against  the  acid,  and  any  necessary  correction 
made. 

If  the  solution  of  soda  be  used  uncorrected,  as  for 
instance  when  9'8  c.  c.  corresponds  to  10  c.  c.  deci- 
normal  acid,  the  proper  result  of  a  titration  with  it 
can  be  obtained  by  regarding  each  9'8  c.  c.  as  equal  to 
10  c.  c.  of  the  acid.  So  if  hydrochloric  acid  be  used, 
and  9-8  c.  c.  of  the  soda  neutralises  10  c.  c.  of  the  acid, 
9-8  c.  c.  is  equivalent  to  0'0365  grm.  HCl. 

If  the  quantity  of  the  stomach  contents  titrated  be 
10  c.  c,  the  amount  of  acid  equivalent  to  the  number 
of  c.  c.  of  deci-normal  soda  solution  added,  multiplied 
by  10,  will  give  the  acidity  per  cent,  in  terms  of  the 
acid  value  made  use  of  in  the  calculation.  If  5  c.  c.  are 
titrated  the  amount  obtained  is  multiplied  by  20,  or  if 
only  2  c.  c,  by  50,  to  obtain  the  percentage  acidity. 

Thus  10  c.  c.  of  a  stomach  contents  required 

N 
7'5  c.  c.   —  soda  =  0-02737  grm.  HCl. 

5  c.  c.      „     375  c.  c.      ,,       =0-013687  grm.  HCl. 
2  c.  c      „     1-5  c.  c.      „        =0-00547  grm.  HCl. 


STANDARD    SOLUTIONS 


03 


IMultiplying  the  first  by  lo,  the  second  by  20,  and 
the  third  by  50,  the  acidity/^;-  cent,  as  HCl  is  0-2737. 


Table  to  show  the  Acidity  per  cent,  in  terms  of  HCl 
when  10  c.  c,  5  c.c,  and  2  c.  c.  of  the  stomach  con- 
tents are  titrated  in  relation  to  the  quantit}^  of 
Deci-normal  Sodium  Hydrate  Sokition  used. 


N  ^.  ^^^ 

HCl  per  cent. 

—  NaHO. 

10 

HCiin 
^raimies. 

10  c.  c.  titrated. 

5  c.  c.  titrated. 

2  c.  c.  titrated,   j 

•I 

0-000365 

0-00365 

0-0073 

0-01825 

•2 

0  "0007 3 

0-0073 

00146 

0-0365 

•3 

o*ooi095 

0-01095 

0-0219 

0-05475 

•4 

0-00146 

0-0146 

0.0292 

0-073 

•5 

0-001825 

0-01825 

00365 

0-09125 

•6 

0-OC2I9 

0-0219 

0-0438 

0-1095 

7 

0-002555 

0-02555 

0-0511 

0-127 

•8 

0-00292 

0-0292 

0-0584 

0-146 

■9 

0-003285 

0-03285 

0-0657 

0-164 

i-o 

0-00365 

0-0365 

0-073 

0-1825 

I -I 

0-004015 

0-04015 

0-0803 

0-20075 

1-2 

0-00438 

0-0438 

0  0S76 

0-219 

1-3 

0-004745 

0-04745 

0-0949 

0-23725 

I '4 

0-00511 

0-0511 

0-1022 

0-2555 

I'd 

0-005475 

0-05475 

0-1095 

0-2737 

1-6 

o-oo5?4 

0-0584 

O-I16S 

0-292 

17 

0-006205 

0-06205 

O-I24I 

0-31 

1-8 

0-00657 

0-0657 

0-1314 

O-32S 

1-9 

0-006935 

0-06935 

O-I3S7 

0-346 

2-0 

0-0073 

0-073 

0-146 

0-365 

3-0 

o'oio95 

0-1095 

0-219 

0-5475 

4-0 

0-0146 

0-146 

0-292 

0-73 

5-0 

0-01825 

0-1825 

0-365 

0-9125 

6-0 

0-0219 

0-219 

0-438 

1-095 

7-0 

o'02555 

0-2555 

O-51I 

— 

8-0 

0-0292 

0-292 

0-584 

— 

9-0 

0-03285 

0-3285 

0-657 

— 

lo-o 

0-0365 

0-365 

0-73 

— 

156  STANDARD    SOLUTIONS 

When  the  acidities  are  expressed  in  terms  of  hydro- 
chloric acid,  it  is  convenient,  for  purposes  of  compari- 
son, to  express  the  chlorine  values  in  the  same 
way. 

Mohr's  Standard  Silve?^  Nitrate  Solution. 

This  solution  contains  29-075  grm.  of  pure  nitrate 
of  silver  in  the  litre,  and  each  cubic  centimetre  corre- 
sponds to  '006  grm.  of  chlorine,  or  'Oi  grm.  of 
sodium  chloride,  or  "00624  grm.  HCl : — 

Thus  '029  X  "2088  —  "006  grm.  chlorine. 

'  '029  X  '3441  =  "01    grm.  NaCl. 

•029  X  -2147  =  -00624  grm.  HCl. 

To  express  chloride  of  silver  in  terms  of  hydro- 
chloric acid,  its  weight  is  multiplied  by  0-25427. 

Solutions  used  in  Martius  and  Liittke's  Method. 

Deci-nornial  Acid  Sohition  of  Silver  Nitrate. 

17  grm.,  or,  more  exactly,  16-997  grm.  of  dry 
and  pure  nitrate  of  silver,  are  dissolved  in  900  c.  c. 
of  a  25  per  cent,  pure  nitric  acid  solution.  50  c.  c. 
of  the  '  liquor  ferri  sulfurici  oxidati '  of  the  German 
Pharmacopoeia  are  added,  the  same  quantity  of  the 
liquor  ferri  persulphatis,  B.P.,  may  be  substituted  for 
this — and  the  mixture  made  up  with  distilled  water 
to  1000  c.  c.  ;  or  more  than  17  grm.  of  the  silver 
nitrate  may  be  used,  and  the  solution  standardised 
against  an  exact  deci-normal  solution  of  hydrochloric 
acid. 

Each  cubic  centimetre  of  the  solution  is  equivalent 
to  one  c.  c.  of  deci-normal  HCl,  or  0-00365  grm. 


STANDARD    SOLUTIONS  ■     1 57 

Deci-norinal  Avimoniuin  Stilphocyanate  Solution. 

When  correct,  this  solution  should  contain  y6 
grm.  of  pure  NH^  CNS  in  each  litre.  To  make  it, 
8  grm.  of  the  salt  are  dissolved  in  looo  c.  c.  of 
distilled  water,  and  the  mixture  standardised  against 
the  acid  silver  solution. 

For  this  purpose  a  burette  is  filled  with  it,  and  lo 
c.  c.  of  the  silver  solution  placed  in  a  beaker  and 
diluted  with  distilled  water  to  about  200  c.  c.  The 
sulphocyanate  solution  is  run  in  until  a  permanent 
red  colour  results.  If  only  9-5  c.  c.  are  required, 
950  c.  c.  of  the  sulphocyanate  solution  must  be  made 
up  to  1000  c.  c.  with  distilled  water. 

The  new  solution  is  now  titrated  a  second  time 
against  the  silver  solution.  If  the  difference  between 
them  be  small,  the  number  of  c.  c.  required  for  10 
c.  c.  of  the  silver  solution  is  noted,  and  the  correct 
result  of  any  subsequent  titrations  worked  out  by  cal- 
culation. If  correct,  i  c.  c.  corresponds  to  i  c.  c.  of  the 
silver  solution. 

Deci-norinal  Solution  of  Nitrate  of  Silver. 

170*  grm.  (AgN03==i7o)  in  the  litre  forms  a 
normal  solution,  therefore  a  litre  of  the  deci-normal 
solution  contains  17  grm. 

I  c,  c.  of  this,  or  -017  grm.  AgNOg,  corresponds  to 
•00365  grm.  HCl. 

That  is,  I  grm.  of  AgNOg  corresponds  to  -2088  grm. 

of  chlorine. 

I  grm.  do.  -2147  grm.  of  HCl. 

I  grm.  do.  '3441  grrn-  of  NaCl. 

*  169-97  grin-  to  the  litre  is  the  absolute  and  exact  amount  necessary 


158 


STANDARD    SOLUTIONS 


Table  showing  the  percentages  of  Chlorine  in  lo  c.  c.  of 
a  fluid  when  tested  with  the  Deci-normal  Solution. 


C.c.  of  Deci- 
normal  Silver 

Chlorine 

HCl 

NaCl 

Nitrate  used. 

per  cent. 

per  cent. 

per  cent. 

I 

•0355 

•0365 

•0585 

2 

•071 

•073 

■117 

3 

•1065 

•1095 

•1755 

4 

•142 

•146 

•234 

5 

•1775 

•1825 

•2925 

6 

■213 

•219 

■351 

7 

•2485 

•2555 

■4095 

8 

•284 

•292 

■468 

9 

•319s 

•3285 

•5265 

lO 

•355 

■36s 

•585 

To  transform  the  figures  for  chlorine  directly  into 
those  for  HCl,  they  should  be  multiplied  by  1-028,  and 
into  those  for  NaCl,  by  1-64.8. 

If  the  solution  of  nitrate  of  silver  employed  be  of 
known  strength  but  not  deci-normal,  the  amount  of 
the  silver  salt  in  the  number  of  c.  c.  used  may  be  mul- 
tiplied by  '2088  to  give  the  amount  of  chlorine  present, 
by  "2147  for  HCl,  and  by  '3441  to  express  the  result 
in  terms  of  chloride  of  sodium. 


STANDARD    SOLUTIONS 


159 


E  "^ 
B  ° 

2  o 
o  b 


go 

o 


o  ° 


E-2 
1^  ° 


O 

--      o 

^   +      I' 
-o  ^    +       a 

-—TO  ^^  I— I 

.H  ^  y  %'^      ■   "^ 

'^00  j.-e  -g  o 


.+ 


O 


•GO 


ao 


■GO 


o 

<! 


+  <u 
"a  in  .2 

,  2    rt    <£ 

o*^  o 


^      + 
+      2 

'S^^  11  • 


iioo"§ 


00  t:j  o» 

+   rt  + 
^  o  + 

+  -5  -=»- 

t^    11    e"^ 
0)   M  g  --I 

^<  sZ 


APPENDIX. 

As,  owing  to  unavoidable  delay,  some  time  has 
elapsed  between  the  preparation  of  the  text  and 
publication,  it  has  been  found  advisable  to  add,  in 
the  form  of  an  appendix,  short  notes  of  several 
recently  devised  instruments  and  methods. 

NeAV   Intragastric   Instruments. 

Fenton  B.  Turck,  of  Chicago,  has  devised  a  number 
of  ingenious  and  useful  instruments  and  methods  for 
the  more  thorough  treatment  and  diagnosis  of  the 
pathological  conditions  of  the  stomach  and  bowels. 

I.  Gyromeles. 

His  gyromele  has  already  been  mentioned,  but  a 
•  further  note  may  be  made  as  to  its  different  modes  of 
application. 

Gyromeles  can  be  introduced  into  the  oesophagus, 
large  intestine,  bladder,  or  other  cavity.  Small  in- 
struments are  made  for  the  posterior  nares.  For 
the  purpose  of  exploring  strictures  of  the  oesophagus, 
ivory  bulbs  can  be  attached ;  and  strictures  can  be 
located  anywhere  from  the  oesophagus  to  the  cardia. 
The  flexible  cable,  encased  in  a  rubber  tube,  proves 
less  dangerous  than  the  stiff,  short  whalebone  formerly 

L 


I  62  NEW    INSTRUMENTS 

used  for  exploring  purposes,  which  is  quite  inadequate, 
and  always  involves  the  danger  of  puncture.  When 
the  ivory  bulb  has  passed  a  stricture  and  entered  the 
stomach  cavity,  revolutions  are  produced  which,  felt 
through  the  abdominal  wall,  prove  that  the  bulb  has 
passed  into  the  stomach,  not  into  a  diverticulum 
at  the  side  of  the  stricture. 

2.  Gastric  Motor  Meter. 

A  small  oblong  rubber  bag  attached  to  one  end  of 
a  small  tube  is  passed  into  the  stomach  cavity,  inflated 
with  air,  and  the  other  end  of  the  tube  connected 
with  a  manometer.  The  records  of  the  manometer 
show  the  longer  respiratory  waves  and  the  shorter 
aortic  and  peristaltic  movements.  The  mercury 
may  rise  30  mm.  during  ordinary  respiration,  200  mm. 
or  more  during  forced  respiration.  In  health  the 
change  of  level  occasioned  by  gastric  peristaltic  move- 
ments varies  from  10  to  15  mm.;  in  cases  of  dilated 
stomach,  only  from  2  to  5  mm.  These  results  point 
to  the  marked  influence  which  the  acts  of  inspiration 
and  expiration  exert  upon  the  mechanical  mixing  of 
the  stomach  contents. 

3.  Stomach  Tube  Filter. 

By  means  of  this  instrument — an  ordinary  stomach 
tube  in  which  the  usual  terminal  apertures  have  been 
replaced  by  a  bulbous  point  penetrated  by  minute 
holes — the  fluid  portion  of  the  stomach  contents  are 
drawn  off  by  aspiration,  free  from  the  solid  contents, 
and  without  risk  of  injuring  the  mucous  membrane. 
By  this  means  the  fluid  toxin-containing  moiety  is 


NEW    INSTRUMENTS  1 65 

removed,  the  solid,  innocuous,  and  nourishing  solids 
left  behind.  Its  use  helps  to  mitigate  the  starvation 
which  necessarily  follows  the  total  removal  of  gastric 
contents  after  each  meal. 


4.  Intragastric  '  Resuscitator.' 

This  is  a  means  of  supplying  heat  locally  to  the 
stomach  walls,  and  more  widely  to  the  whole  organism. 
One  side  of  a  stomach  tube,  divided  into  two  com- 
partments, is  connected  with  a  hot-water  supply 
apparatus,  the  other  side  with  a  graduated  bottle, 
and  the  double  tube  ends  by  passing  into  a  thin 
indiarubber  bag,  which  fits  closely  to  it  when  empty, 
to  the  stomach  walls  when  full  (Fig.  XIII.).  The 
temperature  of  the  water  is  maintained  at  from  20°  to 
1 30°  F.  by  an  automatic  arrangement.  Water  passed 
through  the  bag  in  a  room  is  not  so  promptly  reduced 
in  temperature  as  when  passed  in  and  out  of  the  bag 
within  the  stomach.  Even  when  placed  in  cold  water 
its  temperature  does  not  fall  so  rapidly  as  when 
within  the  stomach  or  colon  ;  but  after  a  certain  time 
elapses  (about  ten  minutes),  the  viscus  reduces  the 
temperature  less  quickly.  (W.  Oilman  Thompson 
has  made  some  interesting  experiments  on  dogs  by 
the  introduction  of  hot  air  into  the  trachea  and  various 
other  parts  of  the  body,  and  observed  a  great  reduction 
in  the  temperature  of  the  air  during  its  passage.) 
The  direct  action  of  this  high  temperature  upon  the 
vessels  within  the  viscus  leads  to  prompt  results 
from  marked  vasomotor  stimulation. 

During  irrigation  of  the  stomach  with  hot  water  by 
this  method,  the  surface  of  the  body  begins  to  glow 


l64  NEW    INSTRUMENTS 

and  the  hands  and  feet  become  warm — results  of  the 
reduction  of  visceral  congestion.  Not  only  is  it  of 
use  in  intestinal  diseases,  but  also  in  cases  of  shock 
marked  by  internal  congestion.  The  method  may 
be  employed  during  operation  where  shock  is  im- 
minent. 

5.  Needle-Douche  and  Double-Force 
Irrigator. 

The  stomach  filled  with  water  is  weighed  down 
hy  the  weight  of  fluid  introduced  in  ordinary  lavage, 
Avhile  only  the  loose,  non-adherent  materials  are  re- 
moved. The  needle-douche  consists  of  a  double  tube 
{Fig.  XIV.),  one  of  the  component  tubes,  smaller  and 
shorter  than  the  other,  ending  in  a  perforated  ball ; 
the  other,  wider  and  longer,  projecting  so  far  beyond 
the  first  as  to  reach  the  fundus  of  the  stomach  when  it 
is  blown  up  with  air,  while  the  bulbous  end  of  the  first 
just  reaches  beyond  the  cardiac  orifice.  After  infla- 
tion of  the  stomach  with  air  passed  through  the 
smaller  tube,  a  strong  stream  of  water  propelled  down 
it,  causes  the  formation  of  a  shower  of  fine  jets 
striking  the  walls  of  the  viscus  with  considerable 
force.  The  water  is  at  once  returned  through  the 
longer  and  wider  tube,  sucked  up  by  means  of  an 
aspiration  apparatus. 

The  advantages  of  the  needle  -  douche  are  as 
follow : — 

1.  It  removes  material  from  the  walls. 

2.  The  water  returns  at  once,  avoiding  over- 
distension and  weighing  down  of  the  stomach  with 
water. 


Fig.  13. — Turck's  Gastric  Resuscitator.     (See  page  1(33.) 


y 


Fia.  14. — Turck's  Needle  Douche.    (See  page  164.) 


NEW    INSTRUMENTS  1 65 

3.  It  acts  as  a  vasomotor  stimulant.  By  using  hot 
and  cold  water  from  115°  to  45°  F.  alternately,  it  is  sl 
powerful  muscular  stimulant,  and  quickens  sluggish, 
circulation. 

For  general  purposes  it  is  not  necessary  to  use  a. 
force-pump  to  compress  the  air,  but  simply  a  small 
rubber  bulb  similar  to  that  used  with  an  atomiser.. 
When  hot  and  cold  water  are  used  alternately  twO' 
irrigators  are  necessary.  The  irrigators  are  made  in 
the  usual  way.  A  bottle,  through  the  cork  of  which  a 
glass  tube  passes,  is  connected  with  a  rubber  bulb. 
By  compression  of  the  rubber  bulb  the  air  pressure 
over  the  water  in  the  bottle  is  increased,  forcing  the 
water  out  of  the  bottle  into  the  irrigating  tube.  Thus 
a  shower  is  produced  under  pressure  by  means 
of  a  single  bulb.  By  using  a  glass  Y-tube,  connected 
with  a  single  bulb  attached  to  the  stem  of  the  Y,  the 
ends  of  the  glass  tube  being  attached  to  two  rubber 
tubes,  which  again  led  to  separate  bottles — nam.ely,  the 
hot  and  cold  water  bottles,  the  air  can  be  compressed. 
in  both.  The  outflow  tubes  from  the  irrigators  are 
connected  with  another  glass  Y-tube,  the  stem  of  the 
Y-tube  being  connected  with  a  single  rubber  tube.. 
Hot  and  cold  water  can  be  used  alternately  by  placing 
simple  cut-off  snaps  on  the  tubes  leading  from  the: 
bottles  (see  Fig.  XV.) 

6.  Nebuliser. 

This  instrument  is  practically  a  variant  of  the- 
needle-douche.  The  double  tube  is  the  same,  but,, 
instead  of  water,  a  nebulising  solution  is  converted, 
into  a  fine  cloud  by  the  use  of  a  nebulising  bottle. 
From  this  bottle  the  suspended  particles  traverse  a 


1 66  NEW    INSTRUMENTS 

second  bottle  provided  to  arrest  any  stomach  contents 
ejected,  and,  along  with  air,  are  forced  into  the 
stomach,  the  air  and  particles  not  arrested  there 
escaping  by  the  second  tube.  Oleum  caryophylli, 
and  oleum  cinnamomi,  in  equal  parts,  along  with  15 
per  cent,  of  menthol,  act  as  a  powerful  analgesic  when 
applied  in  this  way  ;  as  antiseptics  and  as  vaso- 
motor stimulants,  camphor,  or  creolin,  lysol,  formalin, 
and  other  bodies  may  be  used. 

7.  Intragastric  Capsule. 

Each  capsule  contains  in  a  gelatine  capsule  a  small 
piece  of  rubber  tubing,  through  slits  in  which  strips  of 
Congo  red,  dimethyl-amido-azo-benzol,  and  ampho- 
teric litmus  papers  are  inserted  ;  one  or  two  small 
lead  shot  are  attached  to  the  lower  end  of  the  silk 
thread,  by  which  the  capsule  containing  the  rubber 
tubing  is  lowered  into  the  stomach.  The  shot  are 
added  to  facilitate  the  passage  of  the  capsule  down- 
wards through  the  gullet  and  to  the  dependent 
portion  of  the  stomach.  A  piece  of  bread  given  with 
the  capsule  often  assists  in  its  deglutition.  Five 
minutes  are  to  be  allowed  after  its  entrance  into  the 
gastric  cavity,  by  which  time  the  gelatine  has 
melted,  the  rubber  tube  expanded,  and  the  test 
papers  come  in  contact  with  the  contents.  The 
advantages  claimed  are  as  follow : — 

1.  No  tube  has  to  be  swallowed. 

2.  The  use  of  the  capsule  is  perfectly  free  from  risk 
in  cases  of  ulcer. 

3.  It  can  be  used  frequently  without  prejudice  to 
the  patient,  his  disease,  or  his  organs. 

4.  It  excites  no  flow  of  gastric  juice. 


J.  15.-Turck's  double  force  Gastric  Irrigator  and  Aspirator.     (See  page  1(55.) 


NEW    TESTS  167 

5.  After  patients  have  become  accustomed  to 
swallowing  these  capsules  the  later  use  of  the  stomach 
tube,  if  necessary,  is  rendered  easier. 

6.  A  microscopical  examination  can  be  made  from 
the  drop  of  contents  always  removed  from  the  stomach 
in  the  lumen  of  the  tube. 

Mechanical  Vibrator  (Herschell). 

Dr  Herschell  recommends  the  use  of  apparatus  for 
producing  mechanical  vibrations  with  which  he  has 
successfully  treated  cases  of  atony  of  the  stomach  and 
constipation.  The  vibrator  consists  of  an  oscillating 
rod  in  a  handle  to  which  a  reciprocatory  motion  is 
communicated  by  means  of  a  revolving  cable,  this  in 
its  turn  being  rotated  by  an  electromotor.  The 
vibrating  rod  terminates  in  a  disc,  or  other  suitable 
appliance  for  application  to  the  body  of  the  patient. 
The  effect  of  vibration  applied  to  the  epigastric  region 
is  in  most  cases  to  dilate  the  pupil,  to  increase  the 
tension  of  the  radial  pulse,  and  to  contract  an  atonic 
stomach.  In  many  cases  it  is  possible  at  once  to 
empty  a  distended  and  dilated  stomach  by  this  means, 
and  to  procure  passage  of  the  contents  into  the 
duodenum. 

Tests. 

Alpha- Naphthol  test  for  free  Hydrochloric  Acid. 

Winkler  *  recommends  alpha-naphthol  as  a  test  for  the  presence 
of  free  hydrochloric  acid.  One  or  two  drops  of  a  5  per  cent, 
alcoholic  solution  of  this  reagent  (or  10  per  cent,  in  chloroform) 
added  to  a  small  quantity  of  stomach  contents  in  a  porcelain 
basin,  along  with  a  few  grains  of  dextrose,  causes  the  appear- 

*  Centralblatt fiir  innere  Med.,  1897,  xviii,  39. 


I  68  NEW    TESTS 

ance  of  a  fugitive  blue-violet  coloui'  round  the  edges  of  the 
mixture  when  it  is  carefully  heated  to  dryness.  The  sugar  ma}-- 
be  dissolved  beforehand  in  the  alpha-naphthol  solution. 

Test  for  Lactic  Acid. 
Arnold*  uses  a  solution  of  gentian-violet  (o'2  c. c.  saturated 
alcoholic  solution  in  500  c.  c.  distilled  water),  and  5  c.  c.  of  the 
Tinctura  ferri  perchloridi,  U.S.  Pharm.,  with  20  c.  c.  distilled 
water  to  determine  the  presence  of  lactic  acid.  A  drop  of  the 
iron  solution  strikes  a  blue  colour  with  i  c.  c.  of  the  gentian- 
violet,  which  alters  to  a  green  or  yellow-green  when  a  few 
drops  of  gastric  contents,  should  they  contain  lactic  acid,  are 
added. 

*  Journ.  Amsr.  Med.  Assoc. ^  1898,  viii,  p.  21. 


TABLE    OF    AUTHORITIES 


NAME 

PAGE 

NAME 

PAGE 

Arnold 

.    168 

Giinzburg     . 

4i,. 

92,  97,  150 

Baradini 

.   129 

Hari    . 

.     66 

Baumann     . 

.         .         .87 

Hayem 

•       59,  91 

Beneke 

3 

Hemmeter  . 

.    Ill 

Biernacki 

.     62 

Herschell      12,  2 

0,  I 

24,  126,  167 

Boas,   II,  2C 

),  24,  42,  44,  57,  91, 

Hoffmann    . 

62,  8t,  89 

133.  151 

Hoppe-Seyler 

.'    66 

Bourget 

12 

Ruber 

.   no 

Braun 

.         .       85,  89 

Jaksch,  van 

•       39,  52 

Calm  . 

56,  91 

Jaschtschenko 

.   114 

Cassaet 

.   107 

Jaworski 

.     26 

Colosanti 

.   106 

Contejean 

84,  89 

Kerley 
Kinnicutt     . 

•   139 

■     24 

Dehio . 

.   114 

Kleinert       . 

•     31 

Einhorn 

114,  121,  127,  131 

Klemperer  . 

12,  III 

Ewald 

.    108,  116,  128 

.     62 

Langermann 

Faber . 

.    112 

Leo 

24, 

40,  91,  100 

Fehling 

.   152 

Lepine 

.     41 

Fleming 

.  "5 

Leube 

•    9. 

12,  14,  102 

Fremont 

3 

Liebermann 

.       67,  76 

Friedlieb 

.   121 

Lugol . 

.   152 

Llittke 

54, 

69,  91,  156 

Gamgee 

2 

Germain-Se 

e        .         .         .12 

Martius 

54, 

69,  91,  156 

Gillespie 

.         .         .        74,82 

Mathieu 

•      56,  116 

Gmelin 

.         .         .        24,28 

Mering,  von 

•     91 

I/O 


TABLE    OF    AUTHORITIES 


NAME 

Mierzynski 

PAGE 

86,  89,  150 

NAJIE 

Scott  Battams 

PAGE 

•  .   138 

•  36,  150 

•  51,  91 

.  no 

Mintz  . 

48,  57,  91 

Shellbach    . 

Mohr  . 

•  36,  42;  93.  15I;  156 

Sjoqvist 

Moritz 

.    112 

Stein  . 

Oppler 

•     99 

Strauss 

24,  46,  66 

Penzoldt 

.   112 

Tarnier 
Terre 

•  139 
.  107 

Reichmann 

.   144 

Tiedemann  . 

.     24 

Remond 

.   116 

Thompson,  Oilman 

.  163 

Riegel 

.     12 

Toepfer 

•       35,  65 

Rosenheim 

24,  62 

Turck         106,  114, 

122,  132,  161 

Rosin . 

.     24 
.   144 

Rossbach 

Uffelmann  , 

•      41,  151 

Sahli  . 

.     87 

Vierordt 

4 

Salkowski 

•     54 

Volhard       . 

70,  80 

Sappey 
Schmidt 
Schreiber     . 

.       4 
2,  26 
.     24 

Winkler 
Winter 

.    167 

59,  91 

Schiile 

.       8 

Ziemssen     . 

.  125 

INDEX 


Absorption — 

By  Stomach,  power  of,  112 

Tests  for,  112 
Gastrograph  in,  ill 
Gyromele  in,  133 
Potassium  Iodide  in,  112 
Rhubarb  in,  113 
Acid  Albumin,  loi 
Acidity — 

Classification  of,  143 

Estimation  of,  38 

Of  Acid  Salts,  32,  61 

Of  Acid    Salts  combined  with 

Proteids,  51 
Of  Gastric  Contents  in  Disease,  23 
Of  Gastric  Juice,  143 
Of  Hydrochloric  Acid,  48 
Of  Organic  Acids,  40,  59,  74 
Of  Stomach  Contents,  4,  32 

Constituents  of,  32 
Qualitative — 

Free  Acids  due  to,  38 

Organic  Acids  due  to,  42 
Quantitative — 

Hydrochloric  Acid,  free,  48 

Hydrochloric  Acid,  organically 
combined,  51 

Hydrochloric  Acid,  total,  56, 

59,  65,  74 
Organic  Acids,  40,  59,  69,  74, 
84 
Total,  32,  38 
Varieties  of — 

Hyperacidity,   144 
Hypoacidity,  145 
Acidity — 

In  Atrophic  Gastritis,  146 
In  Cancer  of  Stomach,  14-6 


Acidity — 

In    Catarrh,    Chronic    Gastric, 

14s 
In  Cirrhosis  of  Stomach,  145 
In  Dilated  Stomach,  144,  146 
In  Dyspepsia,  Atonic,  145 
In     Dyspepsia,    Nervous,    82, 

^45  ^        . 

In  Erosions,  Gastric,  143 

In  Fevers,  146 

In  Gastritis,  Acute,  147 

In  Ulcer,  Gastric,  144,  145 

Methods    for    Estimation   (see 
Methods) 

Significance  of,  92 
Acidities — 

Table  of  Methods,  87 
Acids — 

Acetic,  43,  84,  85,  104 

Butyric,  43,  84 

Carbolic,  42 

Citric,  43 

Hydrochloric,  48 

Lactic,  5,  43,  83 

Nitric,  60,  64.  80 

Phosphoric,  68 

Sulphuric,  53 

Tartaric,  43 

Trichloracetic,  104 
Activity  of  Gastric  Juice,  96 

Tests  for,  96 

Gunzburg  and  Sahli's,  97 
Oppler's,  99 
Albumin,  102 
Albumoses,  102 
Aldehyde.  44 

Alizarin  Sulphonate  of  Soda,  65 
Alpha-naphthol,  167 


ir 


INDEX 


Amount  of  Stomach  Contents,  23 
Apparatus — 

Electrical,  124 

List  of,  149 
Author's  Method,  74 
Auto-la  vage,  119 

Bacteria  in  Stomach  Contents,  30 

Battery,  Electric,  125 

Benzo-purpurin,  39 

Bilberries,  Dye  from,  41 

Bile,  28 

Blood,  27,  40 

Bordeaux  Wine,  40 

Bucket,  Stomach,  20 

Butyric  Acid,  43,  84 

Cacodyl,  46 
Cancer  of  Stomach,  146 
Cane  Sugar,  Inversion  of,  85 
Capacity  of  Stomach,  3 
Carbolo-Ferric  Solution,  42 
Chlorine,  52-64 
Clapotement,  115 
Classification   of   Gastric  Condi- 
tions, 143 
Cochineal,  34 
Congo  Red,  39 
Contents  of  Stomach — 

Amount  of,  23 

Appearance  of — 
Macroscopic,  22 
Microscopic,  29 

Blood  in,  27 

Fasting,  after,  9 

In  Disease,  23 

In  Health,  4 

Length  of  stay,  9 

Mucus  in,  26 

Normal  amount,  3 

Obtainal  of,  15 

Pus  in,  29 

Smell  of,  25 

Specific  Gravity  of,  24 

Test  for  Proteids  in,  107 

Undigested  Food  in,  25 

Deci-normal  Solution,  33,  152,  159 
Dial  Collector,  125 
Diaphanoscope,  132 


Digestive  Power,  96 
Dimethjd-amido-azo-benzol,  65 
Dilated  Stomach,  3,  26,  123,  133- 

134,  144-148  _ 
Direct  Electrisation,  126 
Double-Force  Irrigator,  164 
Douche,  Needle,  164 
Duration  of  Digestion,  8 

In  Diseases  of  Stomach,  148 

Elastic  Fibres  in  Contents,  31 
Electrisation,  External,  128 

Internal,  130 
Emerald  green,  41 
Equivalents,    Normal     Solution, 

159 
Erosions,  Gastric,  143 
Ethers  of  Organic  Acids,  44,  88 
Evaporation,  Method  of  Testing 

Acidities  h^\  49,  59,  74 
Examples  of  Methods,  Practical — 

Acidity,  Combined  Organically, 

49 

Free,  49 

Organic,  83 

Total,  37 

Author's  Clinical,  82 
Evaporation,  by — 

Hayem  and  Winter,  64 

Martius-LiJttke,  72 

Mintz,  49-51 

Mintz-Boas,  58 

Sjoqvist,  55 

Toepfer,  68 
Quantity  of  Stomach  Contents, 

117 
Expression,  Method  of,  20 

Faradisation,  129 
Fasting  Stomach,  9 
Filtered  Contents,  Specific  Grav- 
ity of,  24 
Forced  Feeding,  135 
Formic  Acid,  44 
Free  Acids,  38,  48 
Free  Hydrochloric  Acid,  41 
Free  Organic  Acids,  42 
Fuchsin,  41 
Functional  Diseases  of  Stomach, 


INDEX 


/  6 


Galvanisation,  112 
Gas,  filling  Stomach  with,  108 
Gas  Volumetric  Method,  86 
Gastric  Contents,  Normal,  4 

Digestion,  in  Stages  of,  5 

Fasting,  9 

Obtainal  of,  15 

Stay,  duration  of,  8 

Test  Meals,  11 
Gastric  Juice,  Normal,  i 

Activity  of,  3,  97 

Composition  of,  2 

Quantity  of,  3,  116 
Gastric  ^lotor  Meter,  162 
Gastric  Spray,  121 
Gastro-diaphanoscope,  132 
Gastrograph,  ill 
Gastro-succorrhoea,  144 
Gastro-xjTisis,  144 
Gavage,  135 
Gentian  violet    as  Test  for   free 

HCl,  168 
Giinzburg's     Reagent     for     free 

HCl,  41,  48  ;   and  Sahli's  test 

for  Activity  of  Contents,  97 
Gyromele,  132,  161 

Haemin,  28 
Haemoglobin,  28 
Hydrochloric  Acid,  41,  48 
Hyperacidity,  144 
Hyperchlorhydria,  144 
Hj-persecretion,  144 
H3-poacidit}',  145 
H5'pochlorhydria,  145 

Illumination  of  Stomach,  132 
Infants,  Methods  in,  135 
Intragastric  Capsule,   166 
Intragastric  Irrigator,   164 
Intragastric  Resuscitator,  163 
Inversion  of  Sugar,  85 
Iodoform,  44 

Iron,  Perchloride  of,  42-46,  1 10, 
168 

Key,  Electric,  125 
Kymograph,  iii 


Lactic  Acid,  5,  43,  83 
Lavage,  118,  140 

Auto-,  119 
Liquefying  Bacteria,  30 
Litmine,  35 
Litmus,  35 

Macroscopic  Appearance  of  Con- 
tents, 22 
Massage  of  the  Stomach,  134 
Mechanical  Methods — 

In  Adults,  118 

In  Young  Children,  135 
Mechanical  Vibrator,  the,  167 
Methods — 

For  Power  of  Absorption,  112 
(of  Absorption) 

Acids  (of  Acidity) — 
Free,  38 

Hydrochloric,  Free,  48 
Hydrochloric,      organically 

combined,  51 
Organic,  40,  59,  69,  74,  84 
Total,  32,  38 

Arnold's,  168 

Author's  Clinical,  74 

liraun,  85 

Cahn  and  von  Mering,  56 

Contejean,  84 

Evaporations  by,  74 

Hayem  and  Winter,  59 

Hoffmann,  85 

Leo,  40 

Marlius  and  Liittke,  69 

Mierzynski,  86 

Mintz,  48 

Mintz-Boas,  57 

Sjoqvist,  51 

Toepfer,  65 

Winkler,  167 

Classification  of,  143 

Consideration  of,  90 

Table  of,  87 
Methyl-violet,  40 
Microscopical  Examination,  29 
Motility  of  Stomach,  108 

Gastrograph  Test  for,  iii 

K}-mograph,  ill 

Olive  Oil  in,  in 


174 


INDEX 


Motility  of  Stomach — 

Salol  in  (Ewald)   io8,   (Huber) 
no,  (Stein)  no 
Motor  Meter,  Gastric,  162 
Mucus,  26,  loi 

Nasal  Gavage,  135 
Nebuliser,  165 

Needle  Douche  (Turck),  164 
Nervous  D3rspepsia,  144,  148 
Normal  Solutions,  33,  159 

Olive  Oil,  III 

Oral  Gavage,  137 

Organic  Acids,  40,  59,  69,  74,  84 

Partage,  Co-efficient  of,  88 
Pepsin,  96 
Peptones,  102-104 
Petrissage,  134 
Phenol-phthalin,  34 
Phloroglucin  \'anillin,  41 
Position  of  Stomach,  113 
Probefriihstiick,   il 
Probemittagsbrod,   12 
Proteids — 

Identification  of,  lOl 

Combination  with  Acids,  4-7 

Digestion  of,  96 
Pus,  29 

Quantity  of  Contents,  Ii5 

Rapidity  of  Digestion,  7-9,  97 

Reichmann's  Disease,  144 

Rennet,  loi 

Resorcin,  42 

Resuscitator,  Intragastric,  163 

Rheophore,  125 

Rheostat,  125 

Rhubarb     Test   for    Absorption, 


Saliva,  105 
Salol,  108,  no 
Significance  of  Acidities,  92 
Size  of  Stomach,  4 
Smaragd  Green,  40 
Smell  of  Contents,  25 


Solutions,  Normal,  33,  159 
Solutions,   Deci-normal,   33,  152, 

159 
Solution  of  Reagents,  150-159 
Specific  Gravity  of  Contents,  24 
Splashing  Sound,  1 15 
Spray,  Gastric,  121 
Standard  Solution,  152 
Starch,  105 
Stomach  Bucket,  20 
Stomach,    Dilated,  3,    123,   133- 

134,  144-148 
Stomach  Electrodes,  124 
Stomach  Illumination,  132 
Stomach  Pump,  20 
Stomach  Tubes,  15-21 
Stomach  Tube  Filter,  162 
Sugar,  105 
Sugar,   Inversion  of  (Hoffmann), 

Sulphocyanide  of  Potassium,  42 

Tests-T- 

Absorption  by  Stomach,  112 

For  Gastric  Juice,  Activity,  96 

For  Proteids,  loi 

For  Saliva,  105 

For  Starch,  105 

For  Sugar,  105 

Motility  of  Stomach,  108 

Pepsin,  Secretion  of,  96 

Position  of  Stomach,  113 

Size  of  Stomach,  I13-II4 
Test  meals — 

Bourget,  12 

Ewald  and  Boas,  il 

Germain-See,  12 

Herschell,  12 

Klemperer,  12 

Leube,  12 
Toxines,  ic6 
Trichloracetic  Acid,  104 
Tropseolin,  39 
Tubes,  Stomach,  15,  21 

Uffelmann's  Reagent,  42 

Ulcer,  Gastric,  144 

Undigested  Food  in  Stomach,  25 


INDEX 


Vanillin,  41 

Vibration,  with  Gyromele,  133 
Vibrator,  Mechanical,  167 
Vomit,  the,  15,  32 
Vomiting  in  Infants,  139 

Washing  out  the  Stomach,  118 
In  children,  140 


175 


Water,  filling  Stomach  with,  114. 
117 

Withdrawal  of  Stomach  Contents 
15 

Xantho-proteic  Reaction,  104 

Voung  Children,  Methods  in,  135 


PRINTED   BY  OLIVER  AND   BOYD,    EDINBURGH. 


Qr^\ 


